Office Visit / Sick Exam Form
Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions. We ask that one to two adults be present at your pet’s exam since our exam rooms are too small to accommodate many people. The check-in and check-out processes for all visits will occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Pet's Name
Who should we contact to make medical decisions today?
Owner (Named Above)
Someone Else (Named Below)
Would you like to accompany your pet into the clinic today, or would you prefer a curbside visit and a call from the veterinarian?
In-person visit
Call
Reason for visit:
Please Select
Sick Visit
Heartwork/Tick Test
Fecal/intestinal parasite screen
Deworming treatment
Other
For OTHER, please fill in the reason:
Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply)
Increase in appetite
Decrease in drinking
Itching/Scratching
Vomiting
Excessive Sleeping
Skin Masses
Decrease in appetite
Weight Loss
Shaking Head
Diarrhea
Scooting
Car Sickness
Increase in drinking
Weight Gain
Bad Breath
Urination Issues
Difficulty Rising
Other (explain below)
Behavioral Problem
If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?
Is your pet on any medications
Yes
No
If yes, please list the medication name, dosage, and frequency:
Has your pet ever had any adverse reaction to any medications, vaccinations, or other procedures?
Yes
No
If yes, please provide what medication, vaccination, or other procedure, and the dates:
What brand and type of food do you feed your pet?
How much do you feed?
Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)
Information for measured amount of food:
Do you have insurance for your pet?
Yes
No
Do you give your pet heartworm or flea/tick preventative?
Yes
No
If yes, please indicate the product(s)
Do you wish to take home flea/tick/heartworm prevention today?
Yes
No
Unsure, speak with a veterinarian about recommendations for my pet
Have you seen any fleas or ticks on your pet?
Yes
No
Does your pet come into contact with other dogs? Please check all that apply
None
Grooming
Boarding
Dog Parks
Other
If Other, please explain:
Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.
I understand that financial responsibilities for services are rendered at the time of discharge.
*
I have read and understand
I give Farms Veterinary Clinic authorization to treat as discussed above.
*
Yes
No
In-person visit: Please call or text our team when you arrive to check in. When the doctor is ready to examine your pet, a team member will escort you into the exam room. We ask that you remain seated during the exam and allow a trained patient handler to provide physical support to your pet. Wearing a mask is recommended. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we ask that you return to your vehicle while the doctor and nurses complete the services discussed (such as bloodwork, x-rays, or other therapies). As with curbside visits, we will call or send a secure link for payment after the visit is complete and bring your pet back to you. This will allow for proper cleaning time between patients to keep all of our patients, clients, and team members as healthy as possible.
*
I have read and understand.
Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive.
*
I have read and understand.
Social Media/Photo Permission: Do we have your permission to post photos of your pet online?
*
Yes
No
I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above-mentioned pet.
*
Yes
No
Your Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Your Initials in place of singnature.
*
Submit
Should be Empty: