Layout

Client verification of information

Date

Patient Name *

Name *

First

Last

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Pet verification of information

Layout

Name *

Sex *

D.O.B / Age *

Layout

Species *

Breed *

Color *

Brief reason for visit

What symptoms is the patient exhibiting

Duration of symptoms

Is your pet eating? *

Yes
No

If NO, when did this begin?

Is your pet drinking? *

Yes
No

If NO, when did this begin?

What diet/amount is your pet currently on? *

Is your pet on Heartworm Prevention? *

Yes
No

If Yes, what product are they on?

Is your pet on flea and tick prevention? *

Yes
No

If Yes, what product are they on?

Is your pet up to date on their vaccinations? *

Yes
No

If NO, please circle which vaccines your pet needs today.

Canine (Dog)

Feline (Cat)

FVRCP
FELUK #1 WITH TEST
FELUK BOOSTER
RABIES

Does your pet need a refill on prescription medication (including flea/tick, heartworm prevention, monthly medications, etc.)

Layout

RX *

RX

Is your pet currently on medications or being treated with meds by another clinic?

Layout

RX *

RX

Is there any additional information that we need to know regarding your visit today? (Pet behavior, special requests, etc.)

Additional Services (please circle YES or NO):

If needed for diagnostics or requested by you, can we perform bloodwork on your pet?

Yes
No

If needed for diagnostics or requested by you, can we perform radiographs on your pet?

Yes
No

Does your pet need a nail trim today for $10.00?

Yes
No

Does your pet need their anal glands expressed today for $12.00?

Yes
No

For ear infection / issues patients today:

If needed, can we clean and treat your pets ears? (You may need to follow up in 2 weeks)

Yes
No

If needed, can we sedate your pet for safety of them and staff? (pricing based on weight)

Yes
No

For Pre-Pregnancy visits:

Does your pet need a progesterone test today?

Yes
No

Are you wanting to have AI services performed today?

Yes
No

Is the male to breed with here today?

Yes
No

Has he been collected before?

Yes
No

For Pregnancy Visits:

What are all of the breeding dates (Month/Day) *

If the patient is over 45+ days pregnant, would you like an X-ray?

Yes
No

Are you needing to schedule a C-Section?

Yes
No

Are you on a strict budget today?

Yes
No

Please let us know before the appointment so that we can keep a budget in mind *

Client Signature

Clear Signature

Date *

Patient Check-In Form