New Patient History

New Patient History

Please complete the patient history below. Either submit electronically, or you can print and mail the completed form: Veterinary Wellness Center 9970 Harrison Avenue Harrison, Ohio 45030
Name*

First NameLast Name
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Pet's Name*
Birth date if known, approximate date if not known*
CanineFeline
MaleFemale
yesno
Breed*
YesNo
Please list drugs and dosages:
YesNo
Please list products and dosages:
Please describe your pet's diet (brands, quantities, frequency). Please include 'people food' that you regularly share with your pet.*
Please list the types of treats that your pet receives and how many per day:*
We would like to know how you heard about our special services, or who referred you to us:
What is/are the current problem(s) that prompted this appointment?*
Please provide the names of other veterinarians/specialists that you have consulted about your pet's current problem:
Does your pet have other problems or are there other concerns either current or in the past that you feel may be related or that you may still have questions about?
YesNo
Please describe the abnormality
YesNo
Please describe the weight changes
YesNo
Please describe the energy/activity level:
For the following questions, please indicate yes or no for each question. If you answer yes for any question, please describe the conditions, severity, and frequency of the problem.
Has your pet experienced:
NoYes
Please describe what treatments were prescribed and what was the response to treatment?
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
NoYes
Please describe:
Please describe your goals for this appointment:*
When the staff of Veterinary Wellness Center calls to schedule your pet's appointment, you will be asked to provide a valid credit card number that will be used to gaurantee the reserved time slot.

If you cancel your appointment with less than 24 hours notice or fail to arrive for your appointment, you will be charged for the full examination fee.

By signing below, you acknolwedge and consent to this cancellation/no-show policy.
Name*

First NameLast Name
Signature*

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New Patient History

For the following questions, please indicate yes or no for each question. If you answer yes for any question, please describe the conditions, severity, and frequency of the problem.

Has your pet experienced: