Canine Check In Form (Custom PDF)

Pet's Name*

Date and time of appointment*

Date

Time*

Who is bringing in your dog?*

First NameLast Name

Who is bringing in the pet?*

Phone number to use during visit?*

Current address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please update the primary contact phone number below if needed:

Please enter a valid phone number.

What is the reason for the visit?*

Do you need any prescriptions or flea/tick/heartworm medications refilled?*

YesNo

Please list any medications you would like refilled and we will do our best to have it ready by the time of your appointment:*

Do any of the following apply to your dog?

Stays at a boarding/kennel?Goes to the groomer?Lives with multiple pets in the home?Lives with children in the home?

What flea and parasite control is your dog currently on and when was it last given?*

When was the flea and parasite control last given?

Has your pet experienced any changes in urination or defecation?*

YesNo

Please explain:*

Has your dog experienced any changes in behavior?*

YesNo

Please explain:*

Has your dog had any behavior issues in the past?*

YesNo

Please explain:*

Will your dog be on a sedative for their appointment?*

YesNo

What drug? What time will it be given?:*

Is your dog on any medications, supplements or vitamins? Please list all and the last time they were given.*

What brand of food do you feed your dog? How much and how often?*

Has your dog been seen at any other veterinary practice since your last visit?*

YesNo

May we request records?*

YesNo

Please provide the name and number of the hospital:*

If you have a digital copy or photo of your dog's records you can attach them here

If possible, we ask that you withhold feeding your dog for a few hours before your appointment so we can spoil them with yummy treats! These may include liver treats, peanut butter, or spray cheese. May we give your dog treats?

YesNo

Ok! You are welcome to bring your own treats if you like!

Is there anything else we should know before we see you and your dog?

Our team at Crescenta Cañada Pet Hospital is here to help you care for your pet in the best manner possible. We are always here for you and your pet. Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely,

The Doctors and Team at Crescenta Cañada Pet Hospital

Download our app before your visit!

By signing below, I acknowledge and consent to audio recordings made during my pet’s appointment and physical examination to aid inaccurate medical record keeping. These recordings will be stored in accordance with applicable laws and privacy standards.

By signing below you are also confirming your appointment. We look forward to seeing you and your pet!*