Patient History Form
If you are unable to be present for your pet's examination, we ask that you complete this form so that we have all the pertinent information for your pet's appointment. We appreciate you taking the time to complete this form and share your observations of your pet's health.
Phone Number that you can be reached at ALL TIMES during your pet's appointment
What is the primary reason for your visit?
Wellness Exam, Vaccines
Wellness Exam, Senior Screen
Wellness Exam, Vaccines & Senior Screen
My pet is not feeling well
If your pet isn't feeling well, please share your concerns:
Duration & Frequency of problem(s)
My pet's problem has
Stayed the same
Please list any current symptoms your pet is experiencing
Change in appetite
Change in water intake
Discomfort with ears, skin, feet (i.e., any itching, scratching or licking?)
New or changing skin growths / masses
Limping / Lameness
Change in behavior
Inappropriate urination or defecation
FOR CATS, does your cat go outside or live with other cats that do?
What type of food are you feeding you pet?
How much and how often do you feed your pet?
Is your pet on any parasite preventive? (Heartworm, Flea, Tick)
Please list all medications, supplements and preventives you are giving along with dose and frequency.
Do you need any refills of food, medication or parasite prevention?
CONSENT if my pet is being brought in by someone other than myself:
If I am not able to speak with the doctor at the time of my pet's exam, I consent to any testing or treatment deemed medically necessary. I acknowledge that payment for any services provided is due at the time of discharge and will make sure a form of payment is provided.
If I am not able to speak with the doctor at the time of my pet's exam, I DO NOT consent to any testing or treatments outside of life saving procedures. I acknowledge that there may be a delay in my pets care or additional charges incurred if testing or treatment is needed at a later date.
Should be Empty: