GentleCare Pet Hospital Patient Form

GentleCare Pet Hospital Patient Form

Please fill out the following questions to help us prepare for your visit ahead of time. Please allow only one form per each pet. We look forward to seeing you and your pet!
Pet's Name *
Name *

First Name Last Name
List Co-Owners names, if any:
Email *
example@example.com
How did you hear about us? (Internet? Friend? Signboard? Newspaper?)
Home/Mailing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Additional Phone Number
Please enter a valid phone number.
While case numbers are high with COVID-19- we can only allow pets and employees into the clinic at this time. Our doctor will use one of the following tools to communicate with you during your pet's appointment. Please select your preferred communication method for this appointment: *

FaceTime Video (please list the phone number associated below) Google Duo Video (please list the phone number associated below) Phone Call (please list the phone number to call below)
Phone number to use for this appointment:
What vehicle make/model/color will you arrive in? Upon arrival please park behind our plaza- at our back door #21515. You'll see a red awning over the door. *
Vehicle Make/Model/Color
Sex of Pet: *

Male- Intact Male-Neutered Female- Intact Female-Spayed
Color of Pet: *
Breed of Pet: *
List Main Concern/Reason for Visit: *
Provide details in regards to symptoms seen at home and note how long have symptoms been present: *
List past major medical problems, if any:
List medications pet is currently taking and how often:
If your pet is on Heartworm preventive, please list the brand used:
If your pet is on Flea preventive, please list the brand used:
What kind of food do you feed? (input brand if known, describe dry or wet and puppy or adult) *
How is your pet's appetite? *

Normal Less than usual More than usual Not eating at all Unknown
How is your pet's water intake? *

Normal Less than usual More than usual Not drinking at all Unknown
Check all that describes your pet's stool (bowel movement): *

Normal Frequent urge to eliminate Straining seen upon attempt to eliminate Accidents in house Unusual in color None seen within 24 hours Unknown
Check all that describe your pet's urine: *

Normal Frequent urge to eliminate Straining seen in attempt to eliminate Accidents in house Unusual in color None seen within 24 hours Unknown
Has your pet vomited lately? *

No Yes Unknown
Has your pet been sneezing recently? *

Yes/Frequently Occasionally No Unknown
Has your pet been coughing lately? *

Yes No Unknown
Select most appropriate option for activity level: *

Normal Lethargic/Less active Unknown
Do you do dental care at home? If yes, please describe type of care.
Please check all that relate to your pet's lifestyle: *

Mostly indoor Mostly outdoor Strictly indoor only Other dogs in house Other cats in house Visits grooming, boarding or training facilities Visits dog parks Frequent or recent exposure to wildlife
Has your pet had vaccines from another facility? *

No Yes, less than 1 year ago Yes, 2- 3 years ago Yes, More than 3 years ago Never had vaccines Unsure
If vaccines were done elsewhere, please the provide name of the facility:
Upload images/documents of your prior records here:

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