Patient Intake Form
If you are a new or existing client please complete the from below in full. If you have any questions, feel free to contact the clinic at 613-531-3334 to speak with a member of our team.
I am.....
a new client
an existing client, but my address, phone number or email has recently changed.
an existing client
Owner's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Pet's Name & Species
*
Name
Species
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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?
Hospital Location
Personal Referral
Internet Search/Website
Yellow Pages
Hospital Sign
Newspaper/Print
Other
If other, please specify:
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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
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Updated Contact 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
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Section 3 - Patient Intake Questionnaire
Date your appointment is scheduled for:
*
-
Month
-
Day
Year
Date
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:
Please attach a picture of the back of the bag with calories and feeding guidelines:
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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
INTERECEPTOR PLUS (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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