New Patient Check-In
This is the check-in form for new patients and new clients. Please fill in the information below and provide as much detail as possible. Thank you! We look forward to meeting with you!
Partner / Co-Owner
Street Address Line 2
State / Province
Postal / Zip Code
Cell Phone Number
Secondary Phone Number
Your pet's name
Dog or Cat
Color / Markings
Age / Date of Birth
Relevant Medical History
Major medical events or health issues that have occurred in the past
Current Health Concerns
What you would like to discuss with the veterinarian
Current Food and Amount fed per day
Please indicate brand of food and type -- kibble / canned / homemade / raw / etc.
What type of protein is in the food?
Please let us know what type of protein makes up the majority of your pet's food -- is it chicken-based? Beef-based? a variety? How often do you rotate proteins?
Does your pet get treats in addition to the regular food? Please indicate what type of treats they get.
Does your pet currently have a good appetite or have they been eating more than usual? Or more finicky about eating? How long has this been occurring, or is this typical?
Is water consumption normal, increased or decreased?
Is your pet urinating normally? If you have a cat, do they use the litterbox consistently?
Is your pet defecating normally? Is there soft stool / diarrhea or constipation?
Has your pet been vomiting recently? If so, how often?
Coughing / Sneezing
Is your pet showing any signs of a cough or sneeze? Any discharge noted? Is it clear / cloudy / yellow in color?
Please list all medications your pet is taking -- and indicate whether they are currently on the medication or if it has been recently discontinued. If possible, list name of medication, dosage and frequency.
Please list all supplements or additions to the food that your pet is currently taking. List name of supplement, amount, and dosing frequency.
Are there any supplements that you have tried in the past for this issue? Did they have an effect?
Current / Past Therapies
What types of therapies have you tried for your pet to help with this issue? Acupuncture, Chiropractic, etc?
Heartworm Preventative (Dogs Only)
Do you use heartworm preventative? Year-round or Seasonal? What brand?
Flea and Tick Preventative
Do you use a flea and tick preventative? If so, what is the brand you typically use? Year-round or Seasonal?
Is there anything else you would like us to know or be aware of prior to the appointment that is not covered here?
I will attach medical records here
I will email medical records to firstname.lastname@example.org
My pet does not have any medical history
We require past medical records for new patients. Please provide records at least 24 hours prior to your visit. We cannot fully provide alternative or holistic recommendations without medical history. Thank you!
Medical Record Attachment
Attach medical history here, or email to email@example.com
Picture of your pet!
If you have a picture of your pet, we would love to see them!! Thank you!
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