Patient Intake Form NOTE: Please call the hospital at 805-369-2222 to schedule your pet's appointment before submitting this form. Your request will not be confirmed until you've scheduled the appointment with our reception team. Date of Scheduled Appointment* MM slash DD slash YYYY Client Name* First Last Patient Name* What is the Reason For Your Visit?* Patient Information What is your Pet's Current Diet?*Please include the brand, type (wet or dry) and amount fed per day. Is Your Pet on Flea/Tick Preventative?* Yes No Not Sure If Yes, What Brand? Do You Need a Refill of Flea/Tick Preventative Today?* Yes No Is Your Pet on Heartworm Preventative?* Yes No Not Sure If Yes, What Brand? Do You Need a Refill of Heartworm Preventative Today?* Yes No What Medication is Your Pet Currently Taking?*Please list all medications including supplements. Please include name, dose and frequency given. Do You Need a Refill of This Medication Today?* Yes No If Yes, Which Medication? My Pet's Weight:* Is Normal Has Increased Has Decreased Comments My Pet's Appetite:* Is Normal Has Increased Has Decreased Comments My Pet's Water Intake:* Is Normal Has Increased Has Decreased Comments My Pet's Urination:* Is Normal Has Increased Has Decreased Comments My Pet's Stool:*Please check all that apply. Is Normal Has Increased Has Decreased Is Runny Is Soft Is Hard Has an Offensive Odor Comments My Pet Has Been:*Please check all that apply. Sneezing Vomiting Coughing Exhibiting None of the Above Symptoms If your pet has been sneezing/vomiting/coughing, for how long? Diagnostic Authorization Please select one of the options below and let us know if you would like to pre-authorize diagnostics and treatments. Authorization for Diagnostic Treatment*Please select one option. I authorize any diagnostics and/or treatments up to $400.00 I authorize any diagnostics and/or treatments up to the amount indicated below. Please call me with an estimate prior to any diagnostics or treatments. I authorize any diagnostics and/or treatments up to the following amount:* Contact Information Please let us know how you can be reached today. Primary Phone*Email* Preferred Pick-Up Time*
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