Make Appointment
518-885-2550
About
Our Hospital Mission
Veterinarians & Staff
Community Involvement
Independently Owned & Operated
Careers
Celebrating Our 20th Anniversary
Resources
Gift Cards
Helpful Pet Care Links
Payment Options
Download Our App
Discounts
Loyalty Rewards Program
Client Education Library
Forms
New Client Form
Boarding Form
Surgery/Admission Form
Patient Intake Form
Release for Medical Records to Malta Animal Hospital
Shop
Pharmacy
Purina Diets
Services
Behavioral Medicine
Daycare & Boarding
Dental Care
Pet Wellness
Surgery & Anesthesia
View All Services
Emergencies
Contact
Subscribe to Our Newsletter
Full Name
Email
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
Δ
Accepting New Clients!
Schedule Your Appointment Now!
About
Our Hospital Mission
Veterinarians & Staff
Community Involvement
Independently Owned & Operated
Careers
Celebrating Our 20th Anniversary
Resources
Gift Cards
Helpful Pet Care Links
Payment Options
Download Our App
Discounts
Loyalty Rewards Program
Client Education Library
Forms
New Client Form
Boarding Form
Surgery/Admission Form
Patient Intake Form
Release for Medical Records to Malta Animal Hospital
Shop
Pharmacy
Purina Diets
Services
Behavioral Medicine
Daycare & Boarding
Dental Care
Pet Wellness
Surgery & Anesthesia
View All Services
Emergencies
Contact
Make Appointment
518-885-2550
Patient Intake Form
"
*
" indicates required fields
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
Other
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
Comments
This field is for validation purposes and should be left unchanged.
Δ
