Pet Intake Form

Pet Intake Form
Clinic Location*
Owner's Name*

First NameLast Name
Pet's Name*
What are we seeing your pet for today?*
Type of Pet:*

CatDog
Does your pet have any allergies? (food, medication, environmental, etc):*

YesNo
If yes, please list your pets allergies:
Please describe any veterinary specific handling/behavior concerns for your pet that we should be aware of for their visit. For example: fear aggression, dog or cat reactivity, noise sensitivities, etc:
Has your pet ever been given any supplements or prescribed medications to help manage their fear or anxiety associated stressful situations?*

YesNo
If yes, what was it and what sort of results did you experience?
Have you ever had a puppy/kitten before?

YesNoNot in a long time!
Where did you get your puppy/kitten?
Do you know if your pet is due for any vaccines?

YesNoUnknown
If yes, please list which vaccines are due (if you don't know, please leave this blank)
Do you know if your pet is up-to-date on their annual lab work? (This includes annual blood work, heartworm testing, fecal parasite testing, etc.)

YesNoUnknown
If no, do you know what they are due for? (if you don't know, please leave this blank)
What are we rechecking / following up on?
What is our technician assisting you and your pet with at this appointment?
Is this your pet's first acupuncture appointment?

YesNo
Is this your pet's first massage appointment?

YesNo
What are the main concerns you are hoping to address with acupuncture treatment?
What are the main concerns you are hoping to address with massage therapy?
How has your pet been doing since their last treatment?
How has your pet been doing since their last massage?
Do you have any other concerns you would like to discuss today?
Please check any of the following symptoms your pet has recently had:

CoughingSneezingVomitingDiarrheaOther...None of the above
If yes, please explain:
What is your pet's current diet? Type (kibble, wet, raw), brand, amount/frequency:
How has your pet's appetite been recently?

NormalAbnormal
If abnormal, please explain:
How has your pet's water consumption been lately?

NormalAbnormal
If abnormal, please explain:
How has your pet's urinary habits been lately?

NormalAbnormal
If abnormal, please explain:
How has your pet's bowel movements been lately?

NormalAbnormal
If abnormal, please explain:
How has your pet's energy levels been lately?

NormalAbnormal
If abnormal, please explain:
Has your pet had any behavior changes or any behaviors you are concerned about?

NoYes
If yes, please explain:
Have there been any other changes since your last appointment?
Tell us about your dog's lifestyle:

Travel outside of the PNWDog ParksDaycareBoardingGroomingHikingLocal WalksNone / HomebodyBeachRiver
If relevant, please include where your pet travels:
What is your cats current lifestyle?

Indoor onlyOutdoor onlyIndoor/Outdoor
If your cat goes outdoors, have they had a recent viral test?

YesNoUnknown
Is your pet on any medications, supplements, or preventatives?*

YesNo
Just double checking... Does this also include flea, tick, and heart preventatives?

Yes, my pet is not taking any preventativesActually, my pet does take a preventative
Just double checking... Does this also include supplements such as fish oils or joint supplements?

Yes, my pet is not taking any supplementsActually, my pet does take a supplement
When listing medications below please include preventatives (flea, tick, heartworm, etc), supplements (fish oil, joint supplement, etc), and pre-anesthetic medication prescribed by the hospital. If able, please include drug name, type (pill, capsule, liquid, etc), medication strength, the amount given, and frequency given. Please be as accurate as you are able to be.
Please list any current medications:*
Will your pet need any prescription refills today?*

YesNo
Please list medication refills needed:
Has your pet ever had an adverse reaction to any vaccines?*

YesNo
If yes, please list the vaccine(s) and the type of reaction:
Has your pet ever had a adverse reaction to any medications?*

YesNo
If yes, please list the medication(s) and the type of reaction:
Have you recently visited any hospitals or emergency rooms that we can get records from?*

YesNo
If yes, please explain:
Please upload any relevant photos or documents to be discussed at your pet's appointment:

Browse Files

Cancelof
Please explain any uploaded photos or documents:
Should be Empty: