Patient Intake Form

Name*
First Last
Phone*
Patient Name*
Date of Appointment*
MM slash DD slash YYYY
What is the main reason for your pet’s visit today?*
Has your pet experienced any of the following:
- loss of appetite
- vomiting
- diarrhea
- coughing
- sneezing
Loss of appetite: how often and when did the symptoms occur?*
vomiting: how often and when did the symptoms occur?*
diarrhea: how often and when did the symptoms occur?*
coughing: how often and when did the symptoms occur?*
sneezing: how often and when did the symptoms occur?*
What type of food (brand and type) and how much per day does your pet eat?*
Do they get treats?
- Yes
- No
What type, how many, and how often?*
Please list ALL medications and supplements (including dose and frequency) that your pet is on currently.*
What Heartworm, Flea and Tick Preventative is your pet on?*
- Heartgard
- Nexgard
- Bravecto
- Vectra
- Sentinel
- Revolution
- Seresto
- Other
Please specify:*
When was your pet's preventative last given or applied? Have you seen any ticks on your pet's fur or skin?*
As part of your pet’s daily routine, does he/she go outside on leash walks, in a fenced in yard, or outside with free access?
- Yes
- No
Please describe his/her typical environment (wooded, field, body of water….).*
Do you take your pet hiking, camping, running, or do other outdoor activities?
- Yes
- No
Do they go swimming?
- Yes
- No
How frequently?*
What type of water (pond, creek, lake, pool) and how frequently?*
Do they go to the groomer or take baths at home?
- Groomer
- Baths at home
How frequently do they go to the groomer?*
How frequently do they take baths at home?*
Do they go to daycare, training classes, boarding kennel, dog park, or other public dog areas?
- Yes
- No
Does your pet travel with you?
- Yes
- No
Where do you frequently travel?*
Is your house a single or multiple pet household?
- Single
- Multiple
What other animals are in the household?*
Are there young children in the house?
- Yes
- No
Do you need any medication, preventative, or food refills at your pets visit?
- Yes
- No
Please, provide prescription information here.*
What is the main reason for your pet’s visit today?*
- Wellness Visit
- Sick Visit
- Surgery/Procedure
How many litter boxes are in the household? Please describe litter box type, location in house, type of litter, and how frequently it is cleaned.*
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604 State Route 67
Malta, NY 12020 518-885-2550

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