Client In-take Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-Time Phone*
Mobile Phone
Email*
Enter Email Confirm Email
Pet Information
Pet's Name*
Please tell us what symptoms your pet(s) is experiencing?*
(vomiting/diarrhea/abnormal urination/sneezing/eye or nasal discharge/lethargy/not eating or drinking/sores/scratching/licking/chewing/lumps/weight/behavior change/limping/etc.)
When did these symptoms start?
Any previous conditions?
(heart murmur/allergies/etc.)
Are they on any medications/supplements/vitamins?
If yes, what medication(s)/dose/how much/last given?
What heartworm preventative is your dog on & when was it last given?
Is your pet current on their vaccinations (dogs/cats/ferrets/rabbits)?
If yes, where were they given, what vaccines & the next due date?
Has your pet ever been to the vet before, if yes when & where?
Any previous lab work(s)? (blood/stool sample/etc.), if yes, what & when?
Does your dog/cat visit the groomers/daycare/dog parks/etc.?
Cats/Dogs: indoor/outdoor/both?
What is your pet’s diet & how much do they get?
Are they eating/drinking normally?
When & how much did they eat last?
How long have you had them & where did you get them?
How is your pet(s) housed?
Reptiles (enclosure/substrate/temperatures/humidity/lighting (UVB)/etc.) Small mammals/rabbits (enclosure/bedding/toys/indoor or outdoor) Bird (enclosure/substrate/toys)
Do they get out of cage time? How much or often?
Are they housed with any other animals or other animals in the house?
If female bird/reptile, has she produced eggs in the past, if so when & how many?
Any other concerned you would like to discuss today?

Client In-take Form

Owner's Name

Pet Information

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