Patient Check-in / History Form

Patient Check-In History Form
Your Name

First NameLast Name
I am a
My pet's appointment is scheduled for what date?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (required if you gave a P.O. Box mailing address above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Spouse Name
Spouse Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have we ever seen this pet before?

Other
PET'S NAME
SPECIES

Other
SEX
BREED
COLOR
AGE
EX: 1 YEAR OR 1 MONTH (NOT JUST 1)
REASON FOR TODAY'S VISIT
Please provide a detailed list of any specific concerns you would like the doctor to address at your visit. Be sure to include the length of time a problem has been present for, as well as any changes in severity and frequency:
Has this pet been seen for this problem before?
Is your pet current on all vaccinations?
Has this pet seen by another veterinarian? If so name and phone number so we can request the medical records.
The issue began on:
My pet's water consumption / thirst seems:
My pet's volume/frequency of urination seems:
Any vomiting:
Any diarrhea:
My pet's energy level seems:
Does your pet have any lumps/bumps that you would like checked?
If Yes, are any of the lumps/bumps changing or bothering your pet?
Please use the tool below to circle the location of any laceration/ lumps/bumps you would like checked:
What medications (including flea & tick preventative such as NexGard and heartworm preventative) is your pet currently taking? Please include dosage and frequency given, if known:
Please list any medications that your pet needs refilled:
What diet is your pet currently eating? Please include brand, type (i.e. kibble, canned), amount fed and an extra items used, such as treats:
Has your pet's diet changed in the past 6 months?
My pet's appetite seems:
What is your pet's current lifestyle? For dogs, please list any places that are routinely visited outside the house (i.e. dog parks, daycare, grooming). For cats, is any time spent outside? If so, does your cat roam beyond the yard?
Is it possible for your pet to have:

Other
You may use the below tool to take and submit any photos of your pet that you would like us to review with this form:
Are there pictures or video that would help us with our exam today?
Is your pet current on vaccines.
When was the last vaccination date?
Is There Anything Else You Would Like To Discuss Today?
Method of Payment Today
10% Discount
Place of Employment
How did you hear about our clinic? Were you referred by someone and, if so, who?
Type or Sign Full Name
By checking I agree below, you give us permission to photograph your pet for use in customer files, as well as for the Company's website and Facebook page as well as social media posts
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Patient Check-In History Form