Patient Intake Form

Client Name*

Client First NameClient Last Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Patient Information
   Pet Name*      Species (Dog/Cat)*
   Breed*      Gender (M/F)*
   Spayed/Neutered? (Y/N)      Age
   Color
If female and not spayed, when was last heat cycle?   Date

Reason for visit today:*

Primary Care Veterinarian***
Veterinary Hospital* Doctor
***We require this information in order to ensure your primary care veterinarian can be kept up to date on the status of your pet.***

Patient History
Any previous illnesses or surgeries: list any previous illness or injuries
Any allergies to medications, vaccines, or food: (Y/N)
If yes, please list allergies: list any allergies

Patient Medications

Please list medications, how frequently they are given, and when last doses were administered

Diet
Current food pet food brand
Any diet changes? (Y/N)

Weight

LossGainMaintain

Appetite

GoodPoorNone

Is your pet current on vaccines?

YesNo

Last Vaccines

Date given

Is your pet heartworm positive?

YesNo

Is your pet current on heartworm prevention?

YesNo

Heartworm Prevention
Prevention Type? Brand
Last given? Date

Flea Prevention

TopicalOral

Flea Prevention
Brand

Is your pet primarily indoors, outdoors, or both?

IndoorsOutdoorsBoth

***Felines Only***
Has your pet been FIV/FeLV tested? (Y/N)

***Felines Only: If tested, results?***

PositiveNegative

Toxin Exposure
Has your pet potentially been exposed to any plants, toxins, or human medications? (Y/N). If Yes, please list any potential toxins

Are there other pets in the household, and if so please note their health status.

***RESCUES ONLY***
Name of Rescue Group Rescue Group
Contact person Contact person and phone number Phone Number

I attest, to the best of my abilities, all statements above are complete and correct. I understand the emergency room evaluation fee of $165. Exam fee does not include any treatment, diagnostic testing, or medications. Payment is due at the time of service.

I authorize Pearland 288 Animal Emergency Clinic to release my pets' records to my veterinarian and/or insurance company.

Signature*

Client's Signature

Date