Patient Admittance Info Form

Name*

First Last

Phone*

Email*

Date*

PET'S NAME*

PRIMARY COMPLAINTS:*

How long has the problem existed?

Frequency of problem?

Please indicate any additional complaints:

VOMITING
DIARRHEA
COUGHING
SNEEZING
EYE DISCHARGE

Vomiting: please indicate the number of times, substance brought up and color:

Diarrhea: please indicate the appearance and if there was blood visible:

Coughing: please indicate if it is the moist type (productive) or the dry type and if there is choking:

Sneezing: please indicate if there is no, watery or thick discharge:

Eye discharge: please indicate which eye, the appearance of the discharge and if your pet is squinting or rubbing their eye:

Has your pet had an increase in thirst?

Yes
No

Increase in Urination frequency?

Yes
No

Urinating at home?

Yes
No

Urinating in sleep?

Yes
No

Straining to urinate?

Yes
No

Lethargic (Lack of Energy)?

Yes
No

Difficulty breathing?

Yes
No

Normal appetite?

Yes
No

Lameness

Which leg(s)?

Slow getting up?

Cries out?

Able to jump up on furniture?

Able to go up and down stairs?

Uncoordinated?

Falling down?

Turning in circles?

Convulsions and Siezures

How Often?

How Long?

Skin Problems

Is your pet:

Scratching
Biting
Licking

Where on the body?

Sores or Wounds on the Body

Please describe any sores or wounds and where they are on the body:

Flea Prevention

Have you treated your pet for fleas recently?

Yes
No

If yes, what type of flea treatment did you use?

Pet History

Have you fed your pet in the last 12 hours?

Yes
No

Is your pet on any medication?

Yes
No

Medication Type/Brand:

How often?

How long has your pet been on medication?

Has your pet been treated for this problem at another veterinarian?

Yes
No

When/Where:

Please describe any pertinent illnesses or surgical procedures your pet has had in the past:

Monday	8:00AM – 5:30PM
Tuesday	8:00AM – 5:30PM
Wednesday	8:00AM – 5:30PM
Thursday	8:00AM – 5:30PM
Friday	8:00AM – 5:30PM
Saturday	8:00AM – 1:00PM
Sunday	Closed

Lameness

Convulsions and Siezures

Skin Problems

Sores or Wounds on the Body

Flea Prevention

Pet History

Contact Us

Hours of Operation

Emergency Info