LMAH Veterinary Patient History Form

Patient History Form

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.
Important

Due to the COVID-19 crisis, Lake Meridian Animal Hospital, previously Value Pet Clinic Kent may be limiting certain services and wait times may be longer than anticipated. What was routine before COVID is now time consuming and hard. Our team is working harder than ever to keep everyone safe. We truly appreciate your patience and kindness now, more than ever! Please wear a facemask at all times while interacting with our team.
Pet's Name*

First NameLast Name
Your Name*

First NameLast Name
What phone number can we reach you at while your pet is here?*

Area CodePhone Number
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot, or will be otherwise occupied while your pet is here, please ask us about our drop off appointments.
Have you or your pet traveled outside of Washington state in the last 14 days?

YesNo
Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?

YesNo
Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?

YesNo
Reason for your pet's visit today?
This issue began on:
Date
This issue is:
Has your pet had any:

CoughingSneezingVomitingDiarrhea
Color
Texture
Frequency
Consistancy
Duration
Blood present?

YesNo
Is the cough productive?

YesNoI'm not sure
Is there mucous present?

YesNoI'm not sure
Color
Has your pet had any:

New lumps or bumpsBehavior changesChanges in mobility
Please describe changes
Location of lumps/bumps
When did you notice them?
Any discharge or odor from bumps?
My pet's appetite is:
If increased or decreased, please provide more information:
My pet's thirst level is:
If increased or decreased, please provide more information:
My pet's activity level is:
If increased or decreased, please provide more information:
My pet's urination is:
Color
Amount
Frequency
Duration of abnormal urination
My pet eats

Wet food onlyDry food onlyWet and dry mixturePeople foodRaw dietHome cooked dietOther
Brand of pet food
If prescription diet, what formulation?
How often is your pet fed?
How much is your pet fed?
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)
Has your pet's diet changed in the last 6 months?

YesNoI am not sure
Is it possible for your pet to have:

Eaten garbageIngested toxins (rat bait, ant bait, other known toxic substances)Ingested MushroomsIngested MarijuanaEaten toys (part of toys missing, chewed up etc.)Eaten grain free diet for any period of timeIngested human or animal medications not intended for them or at higher doses than intended?NONE OF THE ABOVE ARE POSSIBLE
Please tell us more:
Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:
When was your pet's last dose of heartworm preventative?
Date Given (Please type N/A if not on a preventative)
What kind of heartworm preventative do you use?
Name of medication - put unknown if not sure
When was your pet's last dose of flea/tick preventative?
Date Given (Please type N/A if not on a preventative)
What kind of flea/tick preventative do you use?
Name of medication - put unknown if not sure
Is your pet:

Indoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightOther
Are there other pet's in the home

YesNoFarm Animals
Please tell us about the other pet's in your home
Does your pet:

Visit the dog parkGet Groomed RegularlyCompete in Dog/Cat ShowsAttend Obedience TrainingAttend Agility/Dock Diving/Search and Rescue programs etc.BoardAttend Doggie DaycareTravel with you (inside Washington state)Travel with you (outside Washington state)
Is your pet current on vaccinations?

YesNoI Am Not Sure
My pet's vaccines were administered last by:

At Lake Meridian Animal HospitalI Am Not Sure WhereOther
Does your pet have a microchip?

YesNoI Am Not Sure
Has your pet bitten anyone in the last 15 days?

YesNoI Am Not Sure
Does your pet have known health concerns and/or chronic disease or conditions?
If yes, please tell us more. If no, please note N/A
Is there anything else we should know about your pet?
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Browse Files
Please upload if available. Cancelof
Is there anything else you would like to discuss today?
Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
I understand I should remain in my vehicle or maintain a 6 foot distance while on Lake Meridian Animal Hospital grounds. This is for my safety and the safety of others.*
Initial
I understand that access to the Lake Meridian Animal Hospital building is limited to employees only at this time. *
Initial
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, www.lakemeridiananimalhospital.com and any other marketing and/or other social media outlets we may choose to use?

YesNo
I agree to release Lake Meridian Animal Hospital from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old.*
Initial
Lake Meridian Animal Hospital uses email, text and our own hospital app for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders?

YesNo
FINANCIAL POLICY Our office accepts Visa, Mastercard, Discover, and American Express. We do not accept checks. During the COVID-19 pandemic, we are not accepting cash. In addition, we also offer several 3rd party financing options for our clients via Care Credit and Scratchpay. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Therefore, Care Credit cannot be used for PAW plan services. Additionally, the use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity. As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer. Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. The client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your signature below indicates your agreement with these policies.
TREATMENT CONSENT By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Lake Meridian Animal Hospital to examine, prescribe for, or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
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Patient History Form

Important

Client Policies and Procedures