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Specialty Client Intake Form
What service is your appointment with?
(Required)
Cardiology
Internal Medicine
Surgery
Rehabilitation
Reason For Visit
(Required)
What are your specific goals for this appointment?
(Required)
Primary Owner Information
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Phone
(Required)
Secondary Phone
Email
(Required)
Are you military, a first responder, or a veterinary professional?
(Required)
Yes
No
Explain
Do you have pet insurance?
(Required)
Yes
No
If yes, what kind?
How did you hear about us?
(Required)
Billboard
Drive By Location
Facebook/Instagram
Google/Internet Search
My Veterinarian
NextDoor
Friend/Family
Community Event
Grooming/Boarding
If so, who?
If so, which?
Secondary Owner Information (Secondary Authorization for Medical Decisions)
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Email
Relationship
Primary Veterinarian Information
Primary Care Veterinary Hospital
(Required)
Primary Veterinarian
(Required)
Referring Veterinary Hospital (If Different Than Primary)
Patient Information
**Please bring your pet on a leash or in a carrier at the time of your appointment** **Your credit card will be held on file to reserve your appointment. If you need to cancel or reschedule, you must do so 24 hours prior to your appointment. If you do not cancel before 24 hours, arrive over 10 minutes late from your appointment time, or ‘no show’ your appointment, your credit card will be charged a non-refundable $100 fee. If your credit card is unable to process and you would like to reschedule, you will be required to pay the $100 non-refundable fee at the time of your rescheduled appointment.
Name
(Required)
Species
(Required)
Breed
Age/DOB
(Required)
Sex
(Required)
M
F
Uknown
Neutered/Spayed?
(Required)
Yes
No
Color
Last Known Rabies Vaccination
MM slash DD slash YYYY
Additional History/Information
Current Diet
(Required)
Amount Per Day
(Required)
Travel History in The Last Two Years
(Required)
Heartworm, Flea & Tick Prevention
(Required)
Last Date Given
MM slash DD slash YYYY
Drug Allergies or Vaccine Reactions
(Required)
What is your pet’s current activity level?
(Required)
Activity level prior to the current illness?
(Required)
Does your pet seem to be in pain?
(Required)
Yes
No
Where is the pain?
How bad is the pain on a scale from 1-10? (with 1 being least and 10 being worst)
1
2
3
4
5
6
7
8
9
10
What diseases has your pet been diagnosed with? Are they ongoing or resolved?
(Required)
What recent tests have been performed?
Bloodwork
Urinalysis
X-rays
Ultrasound
Other
Explain
Has your pet had any previous surgeries? If yes, list the surgery and date performed?
(Required)
What medications/supplements is your pet currently taking?
ex: Example Drug, 10 mg tablets, ½ tablet, Oral, Twice daily, mm/dd/yy, mm/dd/yy 12:00 PM
Drug Name
Tablet/Capsule Size or Liquid Concentration
Dose
Route
Frequency
Date Started
Last Date and Time Given
Add
Remove
Cardiopulmonary Resuscitation (CPR) Directive
Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
In order to act in yours and your pet’s best interest, we request a proactive decision regarding Cardiopulmonary Resuscitation (CPR) status. Our teams are open to discussing this uncomfortable but important decision with you regarding your beloved pet should you need clarification. The documented overall success rate of CPR in dog and cat species is low (<10%). Unfortunately, there is insufficient data available regarding the success rates of CPR in exotic companion pet patients, however, based on our experiences alongside this limited literature, successful CPR outcomes in exotic patients are even lower. We believe it is our obligation to immediately provide basic life support so that we can focus on meeting the needs of your pet, prior to contacting you. The cost of CPR can be more than $1000 depending on how complicated the circumstances are. The doctor oversees the type and degree of intervention as it is highly case and species dependent.
I am the owner/agent of this pet and AUTHORIZE CPR efforts and accept financial responsibility
I am the owner/agent of this pet and request DO NOT RESUSCITATE (DNR)
