Patient History Form

Patient History Form

Help us get to know your pet
Greetings from Jacksonville Vet!

Whether this is your first time with us, or it's been a little while since we have seen your pet, please fill out this form to the best of your ability so we can ensure you have a great experience during your upcoming visit. Our Doctors require this form at least one week prior to your first appointment in order to thoroughly review and prepare for the time we have together.
Who is the legal owner of this animal?*
First and last name of legal owner. This is the person authorized to make medical and financial decisions for the pet listed on this form.
Optional: spouse or co-owner's name
This person is able to make decisions for this pet please list their full name. Note: the person present during the appointment must be authorized to make medical and financial decisions for this pet.
List your current home address:*
Primary Phone*
This is the best phone number to reach you with results, concerns, or questions about your pet. We will occasionally text this number when your prescription is ready or an appointment is scheduled.
Secondary Phone*
If the first phone number does not reach someone, we will try this number next.
Current email address:*
We will only send emailed invoices, vaccination reminders, and occasionally online pharmacy coupons if you opt in.
Will the owner be the person present for the upcoming appointment?

YesNo
Please list the first and last name of the person bringing the pet to the appointment and the relationship to the pet/owner.
This person should be prepared to communicate to the pet owner regarding making medical and financial decisions for this pet.
What is your pet's name?*
Species

CanineFeline
Add a photo of your pet
What is your pet's birthdate? Approximate is fine if you are not certain.
What breed is your pet?
What color(s) is your pet?
Sex

MaleMale NeuteredFemaleFemale Spayed
Is this your first pet of this species?

Yes. I would love some extra time with the Doctor to discuss all of my pet's care.No. I have owned this species of pet before.
Do you give your pet a heartworm/intestinal parasite product regularly?

Yes, but sometimes I forget to give it.Yes I give it consistently every month.No, I do not give a monthly heartworm preventative.
What brand of heartworm preventative do you give?
Example: Interceptor Plus, Heartgard, or I'm not sure
Do you use a flea and tick preventative regularly?

Yes, I use a flea and tick preventative.No, I do not use a flea and tick preventative.
Flea and Tick Preventative BRAND
If you are not sure leave blank
List any other medications your pet is on
Leave blank if there are no other medications
What brand of food do you feed?
Does your pet have any food allergies?

NO***YES***
Oral health routine (select any/all that apply):

I brush my pet's teethMy pet enjoys chew toysMy pet eats dry kibbleI am concerned about my pet's oral health
Does your pet exercise daily? What kind of exercise does he/she enjoy?
Is your pet mostly indoors or outdoors?
Does your pet go to the dog park, get groomed, go to a boarding or daycare facility?

NoYes
Would you like more information about our boarding facility?
Do you have pet insurance?

YesNo
*Pet insurance is most beneficial when purchased early on, before your pet develops any medical conditions or diagnoses. Once a condition is written in the medical record it will be considered pre-existing. If you choose to get pet insurance, it is wise to have it in place before your first appointment. We recommend researching pet insurance online. Make a decision based on your personal preferences such as budget (premium and deductible), and coverage type (wellness, accident/illness or both).

All pet insurance companies require the customer to pay the vet office directly and be reimbursed by the insurance company.

Our office requires payment in full at the time of service. If you need an estimate during your appointment please feel free to ask for one! If you need a payment plan, we will accept Care Credit. Find out more by clicking the financing tab on our website: www.JacksonvilleVetHospital.com.
What medical concerns do you have about your pet?
What behavioral concerns do you have about your pet?
Does your pet typically have anxiety during his/her vet appointments?
*Please give us a call from the parking lot to check in for your appointment and let the staff know your pet is anxious. We do have options for calming medications prior to your appointment- please call in advance for details.
WE REQUIRE ANY PREVIOUS MEDICAL RECORDS TO BE RECEIVED AT LEAST 48 HOURS BEFORE YOUR PET'S APPOINTMENT. THIS WILL ENSURE OUR VET IS ABLE TO REVIEW YOUR PET'S HISTORY BEFORE THE APPOINTMENT STARTS.

IF WE DO NOT RECEIVE RECORDS 48 HOURS PRIOR TO THE APPOINTMENT, WE MAY ASK YOU TO RESCHEDULE THE APPOINTMENT.

PLEASE MAKE SURE THE RECORDS ARE GOOD QUALITY AND LEGIBLE.

A PDF DOCUMENT IS PREFERRED.

If hard copies are used, please bring them to Jacksonville Vet at least 48 hours prior to appointment.
Please upload you'r pet's complete medical records here:

Cancelof
PLEASE SELECT ONE:*

My pet's records are uploaded successfully.I am contacting my vet/breeder/shelter and will ensure that they have emailed records at least 48 hours in advance of my appointment (JacksonvillevethospitalMD@gmail.com). I understand if no records are received I may be asked to reschedule.My pet has no prior medical history.
Thank you for choosing Jacksonville Veterinary Hospital. We take pride in serving our community and their animals for over 50 years. We very much look forward to seeing you and your pet soon.
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Patient History Form

Greetings from Jacksonville Vet!