Sims Animal Hospital - Intake Form

Patient Intake Form
If you are a new client to our practice, we ask that you fill out the first 3 sections and then proceed to the section that applies to your pet's appointment.

If you are an existing client, please fill out any changes to the first 3 sections and proceed to the section that applies to your pet's appointment.

If you have any questions, please feel free to contact us at the clinic at 613-531-3334.
Section 1 - Client Information
Owner's Name *

First Name Last Name
Co-owner's Name

First Name Last Name
Address

Street Address

Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Alternate Number

Area Code Phone Number
Email
example@example.com
Do you consent to being sent emails from our clinic? *

Yes No
Do you consent to pictures being taken of your pet and for us to post them on social media? *

Yes No
How did you find out about our practice?
If other, please specify:
Section 2 - Patient Information
Pet Information *

Name Species
Breed (if known) Colour
Date of Birth/Age Sex
Spay or Neutered? Identification (e.g. tattoo or microchip number)
Markings Known allergies
Date your appointment is scheduled for: *

Month Day Year
Date
Section 3 - Patient Intake Questionnaire
What is your primary concern today? *
Has there been any vomiting? *

Yes No
If so, when did the vomiting start? *
Has there been any diarrhea? *

Yes No
If so, when did the diarrhea start? *
Has there been any changes in appetite? *

Yes No
If so, when did this start? *
Please list the food brand and indicate amount being fed:
Has there been any changes in thirst? *

Yes No
If so, when did this start? *
Has there been any changes in urination frequency? *

Yes No
If so, when did this start? *
Are there any concerns with mobility? *

Yes No
Is your pet on any medications? *

Yes No
Please list any medications, how often they are given, and when the last dose was administered: *
Flea/tick/heartworm medications:

BRAVECTO (Oral) BRAVECTO (Topical) ADVANTIX SIMPERICA REVOLUTION INTERECEPTOR PLUS (Heartworm) ADVANTAGE MULTI (Heartworm)
Has there been any tick exposure? *

Yes No
Is there anything else we can help you with today?
If you have any photos or videos you feel would help describe your concerns, please upload them by clicking the button below.

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Patient Intake Form

Section 1 - Client Information

Section 2 - Patient Information

Section 3 - Patient Intake Questionnaire