Doctor Appointment Intake Form

Medical History
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email (Please verify the best email to contact. If you do not have an email, type na@gmail.com)*
example@example.com
Pet's Name*
Please enter Diet and Feeding information.*
Check any conditions that currently affect 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? (Type N/A if not applicable)*
Has your pet experienced this condition in the past?*
Have you tried any home or previously prescribed remedies? *
Have you noted any improvment with this / these therapies? (Type N/A if not applicable)*
Please check any additional symptoms that your pet is currently experiencing:*

Not eatingTrouble Urinating or DefecatingWeight gainWeight lossChange in behaviorChange in activity levelIncreased Water IntakeDecreased Water IntakeNo concernsOther
How long has this symptom been occurring and with what frequency? (Type N/A if not applicable)*
Has your pet experienced this symptom in the past?*
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking. (Type N/A if not applicable)*
Has your pet ever had an adverse reaction to vaccination?*

YesNoNot Sure
Please indicate which preventatives or medications (if any) that you would like refilled at your visit:*

Heartworm Prevention )Flea/Tick PreventionOther
As a fear free clinic, we want to ensure a pleasant visit for all of our patients. Will your pet need any special accommodations during their visits? (i.e. treats, toys, muzzle, etc) *
Would you like any of the following ancillary services performed during your appointment:*

Nail TrimAnal Gland ExpressionOther
Are there any additional concerns that you would like to discuss at your pet's 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
Please arrive to your appointment 5 minutes prior to your scheduled time. Due to our current scheduling restrictions, if you arrive more than 10 minutes after your scheduled appointment time, a late fee will be assessed. If you are more than 15 minutes late, we will need to reschedule your appointment.

If you need to reschedule or cancel an appointment, provide 24 hours notice for doctor appointments and a minimum of 48 hours for surgical procedures. Cancellation may be made by phone, text, or email.
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Medical History