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?

Comment

Patient Intake Form

Elgin

dundee (24 Hour emergency)

algonquin

Dundee Animal Hospital