Make Appointment
518-885-2550
About
Our Hospital Mission
Veterinarians & Staff
Community Involvement
Careers
Resources
Gift Cards
Helpful Pet Care Links
Payment Options
Download Our App
Discounts
Loyalty Rewards Program
Anniversary Contest
Forms
New Client Form
Boarding Form
Surgery/Admission Form
Patient Intake Form
Release for Medical Records to Malta Animal Hospital
Shop
Pharmacy
Purina Food Order
Services
Behavioral Medicine
Daycare & Boarding
Dental Care
Pet Wellness
Surgery & Anesthesia
View All Services
Emergencies
Contact
Subscribe to Our Newsletter
Full Name
Email
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
Δ
CLICK HERE FOR COVID-19 UPDATES
About
Our Hospital Mission
Veterinarians & Staff
Community Involvement
Careers
Resources
Gift Cards
Helpful Pet Care Links
Payment Options
Download Our App
Discounts
Loyalty Rewards Program
Anniversary Contest
Forms
New Client Form
Boarding Form
Surgery/Admission Form
Patient Intake Form
Release for Medical Records to Malta Animal Hospital
Shop
Pharmacy
Purina Food Order
Services
Behavioral Medicine
Daycare & Boarding
Dental Care
Pet Wellness
Surgery & Anesthesia
View All Services
Emergencies
Contact
Make Appointment
518-885-2550
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.
*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
Δ