MexiVet Intake Form
Please provide the following information on you and your pet so we can make sure to give you both the best possible care!
OWNER INFORMATION
Full Name
*
Today's Date
-
Year
-
Month
Day
Date
Phone Number
*
Email
*
example@example.com
Emergency Contact
*
Emergency Contact Name/Relationship
*
Address
*
Street Address
Apt/Unit
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Please Select
Word of Mouth
Yelp
Google
Vet Playas
Instagram
Facebook
Nextdoor
NPR
KUSI News
Reddit post
Other
Who told you about us? (so we can thank them 😊)
Patient Details
Pet Name
*
Special diet or prescription food?
*
Approximate Birthdate
*
Approximate Weight
*
Male or Female
*
Species/Breed
*
Is your pet anxious/aggressive?
*
Is your pet spayed or neutered?
*
Please Select
Yes
No
I don't know
Does your pet have a microchip?
*
Please Select
Yes
No
I don't know
A microchip is required for re-entry to the U.S. and can be administered at the vet clinic in Mexico if your dog does not already have one. Cats are not required to be microchipped.
HEALTH CONCERNS/SYMPTOMS
Is your pet exhibiting any of the following?
Vomiting
Loss of Appetite
Constipation
Allergies
Diarrhea
Hair Loss
Lethargy
Cough
How long has the patient been Vomiting?
How long has the patient had a reduced appetite?
How long has the patient been constipated?
How long has the patient been experiencing allergies?
How long has the patient had diarrhea?
How long has the patient been experiencing hair loss?
How long has the patient been experiencing lethargy?
How long has the patient been coughing?
Describe the reason for your pet's vet visit, your main concerns & symptoms, onset, diagnoses, duration, etc.
*
Is this trip primarily for a dental cleaning and/or teeth extractions?
*
Yes
No
Would you like to choose "Clinic 1" or "Clinic 2" for dental services? (See email for detailed explanation of both)
*
Clinic 1 - Light Cleaning (lower cost, no pre-anesthesia blood work option)
Clinic 2 - Deep Cleaning (Pre-anesthesia blood work included, higher total cost)
No preference/earliest availability
Date of injury or start of symptoms described above
/
Month
/
Day
Year
Date
I understand that appointments involving anesthesia and/or blood work require 10 hours of fasting (no food or water)
*
Is your Pet on any medication?
*
Yes
No
What is the name of the medication, the dosage, and how long have they been on it?
*
Would you like to add
Pathology (applicable when having tumors or growths removed)
Blood work
Flea meds
Anal gland expression
Deworming
Grooming (not always possible, but we'll try to accommodate!)
Please describe the grooming you would like (bath, haircut, haircut-length, etc.)
Groomers will do their best to accommodate, however results are not guaranteed.
Please provide a photo example of the type of haircut you would like for your pet.
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Are the vaccines up to date? (If so, please upload below)
*
Yes
No
If not up to date, which vaccines are we updating today? (Rabies vax required for dogs)
*
Rabies (required for dogs if not already up to date)
Parvovirus/Coronavirus
Distemper/Leptospirosis
Bordetella
Other
Are you providing MexiVet Express with your pet’s veterinary records? (If so, please upload below)
*
Yes
No
Please upload vaccination records and medical documents related to this vet visit (videos are ok too!)
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Rabies vaccination is required for dogs to re-enter to the US. If you have a dog riding with us and you don't have a rabies certificate, we can have the vaccine updated during their appointment.
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Lastly, please give us a recent picture of your pet!
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(619) 782-4747 | Info@MexiVetExpress.com | www.MexiVetExpress.com
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