Veterinary Technician Appointment 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.
Owner 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: (check all that apply)
Vaccine booster, please specify which one(s) below
Anal gland expression
Heartworm/Tick test (dogs)
Nail trim
ESQ fluid therapy
Ear cleaning
Blood testing previously recommended by veterinarian
Urine testing previously recommended by veterinarian
Laser therapy treatment
Fecal/Intestinal parasite screen
Cytopoint injection
Other
If OTHER, please describe.
Dog vaccines
DHPP
Lepto
Rabies
Lyme
Bordetella
Canine Influenza
Feline Vaccines
FVRCP/Distemper
Rabies
Feline Leukemia (FeLV)
Are there any additional questions or concerns?
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:
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
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
Critter concierge: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or nurse will call you in your vehicle to discuss your pet’s exam and recommended treatments or preventative measures.
*
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 signature.
*
Submit
Should be Empty: