Online Medical History Form

Online Medical History Form

404 S. Edgemoor, Bldg 100, Wichita, KS 67218 316-683-4641
Full Name:*
Pet's name:*
E Mail Address:
example@example.com
Phone Number*

Area CodePhone Number
Has your address changed?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your pet have veterinary insurance?*

YesNoOther
Would you like information on veterinary insurance?*

YesNo
What is the reason for your pet's visit today? (If a medical concern, when did you first notice the symptoms?)*
What food does your pet eat? (brand, how much per day, wet / dry) What treats and table food do you give your pet?*
Current medication(s), including preventatives, and/or supplement(s):
Which preventative(s) is your pet on?*

Sentinel Spectrum (Heartrowm)Nexgard (Flea/Tick)Revolution (Heartworm/Flea)Seresto CollarNoneOther
When did you give the last dose of preventatives?
Do you need any prescription(s) or preventative(s) refilled at your pet's visit?*

NoYes
(If yes, please list which medication(s), strength, and quantity you would like refilled)
Lifestyle of your pet:

Indoor OnlyIndoor-occasional outdoor trips ;)Indoor/OutdoorOutdoor onlyGoes to doggy daycare, boarding, grooming or dog parksOther
Are there other pets that live in your household? # of Cat(s) # of Dog(s) # of Bird(s)Other # and type
What activities do you do with your pet for exercise?
Have you noticed any of the following in your pet?
Change in appetite?

NoYesOther
Change in drinking or urination?

NoYesOther
Any vomiting?

NoYesOther
Any diarrhea, constipation, other stool abnormalities?

NoYesOther
Coughing, sneezing, nasal discharge or other respiratory signs?

NoYesOther
Mobility concerns? (limping, pain, stiffness) No Yes (Describe)

NoYesOther
Skin or ear concerns? (itching, head shaking, odor, chewing, scooting)

NoYesOther
New lumps or bumps and/or changes in existing lumps?

NoYesOther
What dental care do you provide for your pet at home?
Does your pet have any health or behavior concerns you want to discuss with the doctor?
Please provide any additional information or concerns that you would like to discuss at your pet's visit:
Would you like information on financing options? (Care Credit, Scratch Pay, Varidi)*

YesNo
I give the doctors and staff at Skaer Veterinary Clinic permission to examine my pet, and I understand that I am responsible for payment of service at the time of my pets dismissal.
Signature:*

Clear
Date:*

MonthDayYear
Date
Please submit form within 24 hours of appointment!

A cancellation fee equivalent to the exam fee will be charged for cancellations within 24 hours. Emergency situations are exempt.

** New clients please have all medical history records for patient emailed or faxed to Skaer Veterinary Clinic within 48 hours of appointment. Your appointment may need to be rescheduled if we do not receive records in a timely fashion.

Records may be emailed to hospital@skaervet.com or faxed to (316)683-0817.
Should be Empty: