Patient Intake Form

Owner's Name *

First

Last

Best phone number to reach you during your pet's appointment (please include area code): *

Email address (for records/vaccination history requests and other communications) *

Have you or has anyone in your household exhibited ANY of the following symptoms in the last 14 days- cough, fever, shortness of breath, difficulty breathing?* *

Yes
No
I decline to answer

Patient's Name: *

Patient's Appointment Date & Time

Date

Time

Primary reason for appointment/concerns: *

Patient's Species: *

Cat
Dog
Other

If "Other" species, please specify (avian, reptile, etc.):

Patient's Sex: *

Male
Male/Neutered
Female
Female/Spayed

Is the patient on Heartworm and/or flea & tick preventative? (please check any that apply) *

Yes- Heartworm preventative
Yes- Flea & tick preventative
No
Not sure

Does the patient need any refills of their Heartworm preventative? *

Amount of Heartworm preventative refills (if needed):

Does the patient need any refills of their flea & tick preventative? *

Amount of flea & tick preventative refills (if needed):

Patient's current medication(s)/supplement(s)/vitamin(s): *

Do you need refills on any of the above medications and, if so, which one(s)? *

What type/brand of food does the patient eat? *

Patient's current energy level: *

Normal
Increased
Decreased

Patient's current appetite: *

Normal
Increased
Decreased

Patient's current drinking/water intake: *

Normal
Increased
Decreased

Is the patient experiencing any of the following: (check all that apply) *

Coughing
Sneezing
Vomiting
Diarrhea
None

Patient's urination (select all that apply): *

Normal
Increased
Decreased
Blood present
Dark
Cloudy
Straining to urinate
Strong/foul odor
Other

Any previous history we should know about the patient?

Any additional information that you would like the Veterinarian to be aware of?

Name

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Accessibility by WAH

Patient Intake Form

Elgin

dundee (24 Hour emergency)

algonquin

Dundee Animal Hospital