Annual Feline 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 their 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. Please wear a mask for the visit if you are not feeling well.The check-in process will occur over the phone, so please provide the information below even if you plan 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
Curbside Call
Reason for visit:
Please Select
Annual Physical
Heartworm/Tick test
Vaccines
Other Procedures
For a sick visit, please fill out our Office / Sick Visit Form
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)
Vomiting
Diarrhea
Coughing
Urination Issues
Sneezing
Other (explain below)
If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?
Do you have any other questions for the doctor today?
Would you like any other procedures performed during your visit today?
Nail trim
Ear cleaning
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
Is your pet an indoor or outdoor cat?
Indoor cat
Outdoor cat
What percentage of time does your pet spend outside?
Have you seen any fleas or ticks on your pet?
Yes
No
Do you have other pets?
Yes
No
If YES, 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
I give Farms Veterinary Clinic authorization to treat as discussed above.
*
I have read and understand
Please call or text our team when you arrive to check in. When the room is ready for your pet we will call or text you to enter the building and escort you to the room. 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). Once completed, we will call or send a secure link for payment 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.
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
You initials in place of signature.
*
Submit
Should be Empty: