Appointment Intake Form "*" indicates required fields Your Name* Patient’s Name* Briefly describe the reason for your pets visit today*Is this a recurring issue with your pet?* Yes No How long has this issue been going on? Please answer the following questions: This information is very important for the doctor to make accurate assessments.When is the last time you fed your pet?* Has your pet been coughing?* Yes No Has your pet been sneezing?* Yes No If yes, have they been to a pet park, boarding facility, or have had contact with other pets? Yes No Has your pet been vomiting?* Yes No Has your pet had diarrhea recently?* Yes No How has your pet’s appetite been?* Increased Decreased Normal How has your pet’s thirst been?* Increased Decreased Normal How is your pet’s urination?* Increased Decreased Normal How is your pet’s defecation?* Increased Decreased Normal How is your pet’s activity level?* Increased Decreased Normal Diet, amount and frequency of feeding*Is your pet currently on any flea prevention* Yes No If so, which kind? Is your pet currently on any heartworm prevention* Yes No If so, which kind? Is your pet on any other form of medication or supplement* Yes No If so, please tell us the name and doseDo you have any other questions or concerns to address?In the event a medical/surgical decision must be made for the diagnostic or therapeutic care for your pet, and we are unable to contact you; how would you like us to proceed? *Please Initial*Proceed with care at the discretion of the doctor (additional charges will apply) (You understand that this may mean performing a procedure and may cause your pet prolonged or possible anesthesia) InitialDo not proceed (You understand that this may mean not performing a procedure and may cause your pet prolonged or additional anesthesia) InitialPlease understand that we will make every attempt to contact you should any unforeseen issues arise today. However, in the event of an unforeseen critical emergency, please elect what life-saving measures you would like performed so that we may be in accordance with your wishes: (these are at additional cost). *PLEASE INITIAL:Do NOT perform CPR InitialBasic life support and CPR measures (chest compressions, artificial respiration). InitialAdv life support and CPR measures (IV medications, fluids, etc) (add’l charges may apply) InitialPrint Name (First, Last) First Last Signature of Responsible Party* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.