Appointment Intake Form Appointment Intake Form Owner’s First Name Owner’s Last Name E-mail Best Phone Number For Appointment Day (the clinic staff will use this number to communicate with you through the duration of the appointment) Address Address line 2 StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming City Zip Code Previous Veterinarian (If you don't have a previous veterinarian, please put N/A) Pet's Name Pet's Date of Birth and Age Appointment Date Appointment Time12:00 AM12:30 AM1:00 AM1:30 AM2:00 AM2:30 AM3:00 AM3:30 AM4:00 AM4:30 AM5:00 AM5:30 AM6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM8:30 PM9:00 PM9:30 PM10:00 PM10:30 PM11:00 PM11:30 PM Patient's Species DogCatOther Patient's SexMaleNeutered MaleFemaleSpayed Female Primary Reason for Appointment/Concerns (Please be as detailed as possible) Patient's Energy Level NormalIncreasedDecreased Is the patient on heartworm prevention?YesNoI'm not sure Is the patient taking any flea/tick prevention/treatment? Patient's Medications (N/A if you don't have any medications) Do you need refills on any of these medications and, if so, which ones? (N/A if you don't have any medications) What type/brand of food does the patient eat? How much food is given per day? What treats are given at home? Patient's appetite NormalIncreasedDecreased Drinking/Water IntakeNormalIncreasedDecreased Is the patient coughing?YesNoI'm not sure Is the patient sneezing?YesNoI'm not sure Is the patient vomiting?YesNoI'm not sure Does the patient have diarrhea?YesNoI'm not sure Patient's Urination (Select all that apply)NormalIncreasedDecreasedBlood PresentDarkCloudyStraining to UrinateStrong/Foul Odor Is patient allowed to have treats during their visit?YesNo What additional services is the patient/your pet in need of today? (Please select all that apply) VaccinesPreventative TestingPreventativesNone at this time How will you be paying for this visit?VisaAmerican ExpressMastercardCareCreditCheckTrupanion / Other Pet Insurance Any previous patient's history we should be aware of? Does the patient have any allergies we should be aware of? Any additional information that you would like the veterinarian to be aware of?