Intake Form

Medical History- Albany Animal Hospital

Appointment Intake/Release Form-Please complete this form if your pet is being seen for a medical concern or an appointment you will not be present for.
Full Name*

First NameLast Name
Pets Name *

NameSpecies
Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Please ensure that you are available by phone at ALL times until your pet is released back into your care.
Please enter Diet and Feeding information.*
Check the conditions that apply to your pet.*

CoughingSneezingVomitingDiarrheaEye DischargeDirty/Itchy EarsNasal DischargeLimpingSkin IssueNew or changed lumpNo concernsOther
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Check the symptoms that your pet is currently experiencing:*

Not eatingTrouble breathingTrouble DefecatingTrouble UrinatingWeight gainWeight lossChange in behaviorChange in activity levelNo concernsOther
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations?*

YesNoNot Sure
Please indicate what preventatives or medications you need a refill of:

HeartgardFrontlineNexgardRevolution PlusCredelioInterceptorSimperica TrioOther
Which preventative care procedures are you approving? (Select all that apply)*

Rabies VaccineDistemper VaccineBordetella VaccineInfluenza VaccineLyme VaccineLeptospirosis VaccineFeline Leukemia VaccineFVRCP Vaccine(Fecal) Intestinal Parasite Lab testHeartworm/Tick Parasitology (Blood) testAnnual Full Organ Function Lab Screening (blood work)Pre Op Blood WorkUrinalysisNone of the AboveOther
Are there any other issues/concerns that you would like to discuss at your appointment?
A topical treatment will be applied at the my expense to any pet with evidence of fleas, flea dirt, or ticks. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.*
Please type in your initials
Signature: Please Sign Below*

Clear
Please arrive for your appointment at your scheduled time. Due to our current scheduling restrictions, if you are unable to arrive on time, we may need to reschedule your appointment.
Should be Empty:

Medical History- Albany Animal Hospital