Appointment Form | White Haven, PA | White Haven Veterinary Hospital

(570) 443-0966

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REQUEST APPOINTMENT

(570) 443-0966 (570) 443-0966
88 PA-940
White Haven PA 18661
Mon - Thur: 8AM - 5:30PM
Fri: 8AM - 5PM
Sat: 8AM - 3PM
(Every other Sat)
Sun: Closed
REQUEST APPOINTMENT

About Us
- Our Doctors
- Blog
Services
Forms
New Patients
- New Patient Form
Contact Us
Online Store
In House RX Refills
Care Credit

Appointment Intake Form

Please fill out this form to check your pet in for their appointment at White Haven Veterinary Hospital.

Owner’s First Name

Owner’s Last Name

E-mail

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 Time

Patient's Species DogCat

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 ExpressMastercardCareCredit

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?