Patient Intake FormNOTE: 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 SureIf Yes, What Brand?Do You Need a Refill of Flea/Tick Preventative Today?* Yes NoIs Your Pet on Heartworm Preventative?* Yes No Not SureIf Yes, What Brand?Do You Need a Refill of Heartworm Preventative Today?* Yes NoWhat 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 NoIf Yes, Which Medication?My Pet's Weight:* Is Normal Has Increased Has DecreasedCommentsMy Pet's Appetite:* Is Normal Has Increased Has DecreasedCommentsMy Pet's Water Intake:* Is Normal Has Increased Has DecreasedCommentsMy Pet's Urination:* Is Normal Has Increased Has DecreasedCommentsMy Pet's Stool:*Please check all that apply. Is Normal Has Increased Has Decreased Is Runny Is Soft Is Hard Has an Offensive OdorCommentsMy Pet Has Been:*Please check all that apply. Sneezing Vomiting Coughing Exhibiting None of the Above SymptomsIf 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*Δ
