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!
All cats must arrive in a carrier.

Please note: For cats that may become fractious/aggressive- it is advised to use a soft carrier with multiple zip door openings, to include an opening on the top.

If possible, avoid hard/metal/plastic crates or carriers and carriers with only one door access.
Pet's Name *
Name *

First Name Last Name
Phone number to contact during this appointment: *
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)
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
List Main Concern/Reason for Visit: *
Provide details in regards to symptoms seen at home: *
How long have these symptoms been present? *
Please type NA if this is a healthy/wellness visit.
List past major medical problems, if any:
List medications pet is currently taking and how often:
Heartworm Preventive given monthly at home? *

None Heartgard Plus Sentinel/Interceptor Trifexis Advantage Multi Other
Flea preventive given regularly at home? *

None Nexgard Trifexis Bravecto Advantage Multi Comfortis Over the counter (non-prescription topical) Flea collar Other
Do you do dental care at home? *

None Dental Chews Water additive/oral rinse Brushes teeth
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? (check all that apply) *

None seen Yes- Frequent Yes- Occasional/intermittent Bile (liquid) Food Within hours Within days Within months
Any respiratory concerns? *

No concerns/Normal Heavy/Increased/Labored breathing Sneezing frequently Coughing
Select most appropriate option for activity level: *

Normal Restless Lethargic/Less active Lame
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
How do you anticipate your pet to behave during their visit? (check all that apply)

Friendly Anxious/Nervous Fearful/Evasive Shy/Timid Bites/Nips/Scratches Aggressive toward other animals Aggressive toward people Treat driven Peanut butter driven May need sedative/medication prior to visit Will be medicated/sedated prior to visit
Breed of Pet: *
For mixed breed cats list short hair? Long hair?
Color of Pet: *
Age or D.O.B. of pet: *
Sex of Pet: *

Male- Intact Male-Neutered Female- Intact Female-Spayed
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:

Cancel of
Home/Mailing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is you phone number provided mobile/cell phone that we may text? *

Yes No
List Co-Owners names, if any:
Email *
example@example.com
How did you hear about us? (Internet? Friend? Signboard? Newspaper?)
Should be Empty:

GentleCare Pet Hospital Patient Form