Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We ask that you provide this information 24 hours in advance.Owner Name* First Last Phone*Email* Pet's Name* What type of appointment is this?*I have a scheduled a specific appointment time with a veterinarianI have scheduled a drop off appointmentLate arrivals* I have read and understand If you know that you are going to be late, please contact us to see if we are able to keep your appointment. If you are more than 15 minutes late and you do not contact us, your appointment will be automatically cancelled. Checking In* I have read and understand I understand that I will be speaking with a nurse prior to leaving my pet at Memorial Veterinary Clinic, that can take up to ten minutes. I understand that there is a scheduled drop off and pick up time. Who should we contact to make medical decisions today?* Owner (Named Above) Someone Else (Named Below) Name Reason for visit: (check all that apply) Annual Physical Bloodwork (dogs) Fecal/intestinal parasite screen First Puppy / Kitten Visit Annual physical - unsure of other services that are due. Would like to discuss with veterinarian. Dog vaccines DHPP 1YR DHPP 3 YR Leptospirosis Rabies 1YR Rabies 3 YR Lyme Bordetella Canine Influenza (Bivalent) Unsure, would like to discuss recommendations with veterinarian Feline Vaccines FVRCP/Distemper 1YR FVRCP/Distemper 3 YR Rabies 1YR Rabies 3 YR Feline Leukemia (FeLV) Unsure, would like to discuss recommendations with veterinarian Other procedures: (All procedures at additional cost) Anal gland Expression Nail trim Ear cleaning Sanitary Trim Have you noticed any issues/problems with your pet? Are there any concerns for the following: Increase in appetite Decrease in appetite Increase in drinking Decrease in drinking Weight Loss Weight Gain Itching/Scratching Shaking Head Bad Breath Vomiting Diarrhea Urination Issues Excessive Sleeping Scooting Difficulty Rising Skin Masses (explain below) Car Sickness Behavioral Concern Other (explain below) (check all that apply)If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes No Has your pet any surgical procedures in the past? Yes No Surgical Procedures What brand and type of food do you feed your pet? How much do you feed?* Free fed (food is offered always/whenever hungry) Measured amount (specify how much and how often below) Measured Amount Do you have insurance for your pet?* Yes No Do you give your pet heartworm or flea/tick preventative?* Yes No If so, which ones? Do you wish to take home flea/tick/heartworm prevention today?* Yes No Unsure, speak with a veterinarian about recommendations for my pet What percentage of time does your pet spend outside? Have you seen any fleas or ticks on your pet?* Yes No Do you have other pets?* Yes No Does your pet come into contact with other dogs? None Boarding Grooming Dog Parks Other Please check all that apply Is your pet on any over the counter or prescription medications?* Yes No List current medicationWhen was the last time your pets liver and kidney values were evaluated? Was your pet last seen by a veterinarian at Memorial Veterinary Clinic?* Yes No Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations. I understand that financial responsibilities for services are rendered at the time of discharge.* I have read and understand I give Memorial Veterinary Clinic authorization to treat as discussed above.* I have read and understand Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. If you need to leave your pet for their appointment, please inform the nurse and we will have you sign a drop off consent form and schedule a pick up time.* I have read and understand Social Media/Photo Permission: Do we have your permission to post photos of your pet online?* Yes No Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
