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 Code Phone Number
Has your address changed? *

Yes No
Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
Would you like information on veterinary insurance? *

Yes No
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 Collar None
When did you give the last dose of preventatives?
Do you need any prescription(s) or preventative(s) refilled at your pet's visit? *

No Yes
(If yes, please list which medication(s), strength, and quantity you would like refilled)
Lifestyle of your pet:

Indoor Only Indoor-occasional outdoor trips ;) Indoor/Outdoor Outdoor only Goes to doggy daycare, boarding, grooming or dog parks
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?

No Yes
Change in drinking or urination?

No Yes
Any vomiting?

No Yes
Any diarrhea, constipation, other stool abnormalities?

No Yes
Coughing, sneezing, nasal discharge or other respiratory signs?

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

No Yes
Skin or ear concerns? (itching, head shaking, odor, chewing, scooting)

No Yes
New lumps or bumps and/or changes in existing lumps?

No Yes
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) *

Yes No
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: *

Month Day Year
Date
Should be Empty: