Initial Consult Form

Initial Consultation Form

(Form required for each pet)
Your Name*

First NameLast Name
Pet's Name:*
Species:*

CanineFeline
Where does your pet spend the majority of its time?*
What type(s) of diet is your pet currently on? (Check all that apply)*

KibbleCannedRaw (Store-bought)Dehydrated Raw (Store-bought)DIY RawDIY Homemade
Please list the brand(s) or diet ingredients (if DIY):*
Has your pet ever had a reaction to any food proteins that you are aware of?*

No Known AllergiesChickenTurkeyBeefFishPorkLambDuckVenisonRabbitOther
Please list any additional treats given: (type N/A if none)*
Is your pet current on vaccinations?*

YesNo - never vaccinatedNo - but has had vaccines prior
Which vaccines has your pet had? (please check all that apply)*

Rabies (dog/cat)DHPP (dog)Bordetella (dog)Influenza (dog)Leptospirosis (dog)Lymes (dog)FVRCP (cat)Leukemia (cat)FiV (cats)FIP (cats)
Is your pet current on heartworm prevention?*

YesNo
If YES, what prevention brand do you use. If NO, when was last dose?*
Is your pet current on flea and/or tick prevention?*

YesNo
If YES, what prevention brand do you use. If NO, when was last dose?*
Is your pet on any prescription medications?*

YesNo
Please list ALL prescription medicines your pet is on: (type N/A if none)*
Is your pet on any OTC medications/supplements?*

YesNo
Please list ALL supplements your pet is on: (type N/A if none)*
Please check all applicable (current and prior) health issues:*

Skin issuesEar infectionsEye infectionsItchy SkinAllergic Reaction(s)Vaccine Reaction(s)Heartworm DiseaseSeizuresAllergiesThyroid DiseaseCancerKidney DiseaseLiver DiseaseGrowths/Masses/LumpsCoughing/SneezingDental DiseaseN/A
Please tell us why you would like us to see your pet, what issues specifically you would like addressed/treated, and any goals you wish to reach with your pet's health.*
Please read and sign/agree in order to schedule IC appointment:

1. I understand that IVS requires ALL prior health records (as far back as possible, with lab results included) to be submitted before we can schedule the appointment.

2. I understand that a deposit of $150.00 (the price of the initial consult/exam fee) will be required to schedule, and the deposit will only be refunded if a minimum of 48 hours' notice is given to cancel and/or re-schedule the set appointment.

3. I understand that IVS is a part-time, appointment-only practice. I also understand because of this, that IVS will respond to all inquiries/requests as soon as possible, but that it is possible that it sometimes may take 24-72 hours for a response.

4. I understand that IVS is not a full-service practice and is not capable of seeing urgent, emergent, or surgical cases.

5. I understand that there may be times IVS will have to refer my pet to a regular full-service veterinarian due to scheduling, equipment, and/or availability constraints.
Signature

Clear
Name

First NameLast Name
Should be Empty:

Initial Consultation Form