Meeker Animal Hospital Patient Intake form

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Patient Intake form

Patient Intake form

Please complete the questions and a staff member will be with you shortly to pick up your pet from the car. Thank you for your cooperation as we adapt to the new COVID 19 safety guidelines. Please call the clinic when you arrive 405-279-2727

15Questions

Language

English (US)

1
Owner of Pet* This field is required.Human First Name and Last Name
First Name
Last Name
2
Have you or anyone you have been in contact with had fever, shortness of breath, coughing, or exposed to Covid-19?
YESNO
3
Phone Number* This field is required.Cell phone to use today for patient updates
Area Code
Phone Number
4
Date* This field is required.
Date
Month
Day
Year
5
Pet's Name* This field is required.Pet's Name
6
Reason for Visit* This field is required.Why did you bring your pet in today?
7
Heartworm Prevention* This field is required.What heartworm prevention are you currently using? Do you need a refill? When was your pet's last dose given?
8
Flea and Tick Prevention* This field is required.What type of flea and tick prevention are you using? Do you need a refill? When was your pet's last dose given?
9
Diet* This field is required.What type of food do you currently feed your pet? How much do you feed and how often? What kind of treats does your pet get?
10
Medications* This field is required.What medications or supplements do you currently give your pet?
11
Clinical Signs * This field is required.Is your pet currently showing any signs of coughing, diarrhea, or vomiting?
12
Vaccination Packages* This field is required.Please select which vaccination package you would like today if you are here for vaccinations. If you are not here for vaccinations, please skip this question.
Wellness Package - Canine $119.00
Basic Package - Canine $59.00
Wellness Package - Feline $119.00
Basic Package - Feline $59.00
Equine Vaccine Package with Coggins $145.50
Puppy Vaccinations - $59.00
My pet is current on vaccinations.
I need to speak to a staff member about the vaccines.
13
Add- on Services* This field is required.Please select any add-on services you would like to your package
Proheart 12 - Price Based on Weight- Only for dogs over the age of 1 year old.
Toe Nail Trim - $9.50
Toe Nail Trim with Grind - $19.50
Anal Gland Expression - $21.50
Ear Cleaning - $28.50
Heartworm Test - $25
Pet Odor Eliminator Candle - $9.00
Pill Pockets 60 count bag (Chicken) - $17.27
Refill Royal Canin Diet
No additional services needed
14
Details for the veterinarian * This field is required.Please provide a history of any medical issues that we need to be aware of. If you pet is here for a problem focused exam (sickness), please provide a list of symptoms including when they started. The more detail, the better. Thank you!
Huge
Large
Normal
Small
Ok
Ok
15
Payment Options* This field is required.Please select how you plan to pay today
Credit Card
Care Credit
Scratch Pay
Check
Cash
16
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