New Client Patient Form: Internal Medicine
Client Information
Pet Owner's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Pet Information
Pet Name:
*
Type of Pet:
*
Cat
Dog
Other
What Breed?
*
If you do not know the breed - please write unknown.
Date of Birth:
*
-
Month
-
Day
Year
Date
Sex:
*
Male, intact
Male, neutered
Female, intact
Female, spayed
Approximate Weight (in lbs):
*
Today's Date
*
-
Month
-
Day
Year
Date
Previous WT:
*
Today's WT:
*
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Pet Condition
Primary concern/reason for referral:
*
Please list any current medications including over the counter supplements:
*
Previous Medications
*
Medication Name
*
Medication Strength
*
(mg or mg/ml)
Medication Route
*
Oral
Topical
Injectable
Frequency
*
Does your pet have any exposure to fleas or ticks?
*
Yes
No
Is your pet on flea prevention?
*
Yes
No
Travel history:
*
Current diet including treats or human food:
*
How much are you feeding?
*
Previous diets
*
Any known ingestion of toxins or non-food items?
*
Has your pet experienced any changes in appetite or energy?
*
Have you noticed any weight loss?
*
Has your pet had any increased drinking or urination?
*
Has your pet had any coughing, sneezing, vomiting or diarrhea? If so, please describe and include frequency:
Any eye or nasal discharge?
*
Does your pet ever visit any grooming saloons, dog parks, or socialize with other pets?
*
Please list any other pets in household and if they are experiencing any clinical signs:
*
For cats:
Indoor
Outdoor
Please list all hospitals that your pet has been seen at:
*
RX Filled
Estimate Approved
Procedure Auth Signed
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