Appointment Intake Form

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
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 dose
Do you have any other questions or concerns to address?
Signature of owner*
Date*
MM slash DD slash YYYY
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Comments
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Please answer the following questions: This information is very important for the doctor to make accurate assessments.