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* Date Format: 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?*YesNoNot SureIf Yes, What Brand?Do You Need a Refill of Flea/Tick Preventative Today?*YesNoIs Your Pet on Heartworm Preventative?*YesNoNot SureIf Yes, What Brand?Do You Need a Refill of Heartworm Preventative Today?*YesNoWhat 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?*YesNoIf Yes, Which Medication?My Pet's Weight:*Is NormalHas IncreasedHas DecreasedCommentsMy Pet's Appetite:*Is NormalHas IncreasedHas DecreasedCommentsMy Pet's Water Intake:*Is NormalHas IncreasedHas DecreasedCommentsMy Pet's Urination:*Is NormalHas IncreasedHas 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 $400.00I 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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