Medical Record Upload

The following CHECK-IN forms are on this page:

Medical Appointment Check-In
Boarding Check-In
Medical Record Upload

Medical Appt Check-In Form

APPOINTMENT CHECK IN

Please complete and submit this form BEFORE your appointment time, to ensure our staff is ready when your pet arrives.

"*" indicates required fields

Instagram

This field is for validation purposes and should be left unchanged.

New or Existing Client?

New client

Existing client

How did you hear about us?

Google

Facebook

Mailer

Referral

Drive-By

Other

Tell us where you heard about us from.

Your Name*

First Last

If we have questions for you, is TEXT OK?*

YES

Best Mobile Phone Number for Text

Address*

Street Address Address Line 2 City State ZIP Code

Primary Email*

Mobile Phone*

How many pets are you bringing in?

Pet 1

Have we seen this pet before?

Yes

Pet Name*

Species*

Breed*

Gender / Fixed*

Color*

Age*

Current diet, amount fed, & frequency*

Last Veterinary Visit*

MM slash DD slash YYYY

Rabies Vaccine Current?*

YES

NOT SURE

Pet have known allergies? Please list, or state "N/A".*

Eating & Drinking normally?*

YES

NOT SURE

Coughing and/or Sneezing?*

YES

NOT SURE

Pet currently on Flea / Tick Preventative?

YES

NOT SURE

If "YES" to Flea / Tick, which brand?

Currently on Heartworm Preventative?

YES

NOT SURE

If "YES" to Heartworm, which brand?

What other medications is the pet currently on?

"None" if none.

Pet 2

Have we seen Pet 2 before?

Yes

Pet 2 Name*

Species 2*

Breed Pet 2*

Gender / Fixed Pet 2*

Color Pet 2*

Age Pet 2*

Pet 2 Current diet, amount fed, & frequency*

Pet 2 Last Veterinary Visit*

MM slash DD slash YYYY

Pet 2 Rabies Vaccine Current?*

YES

NOT SURE

Pet 2 have known allergies? Please list, or state "N/A".*

Pet 2 Eating & Drinking normally?*

YES

NOT SURE

Pet 2 Coughing and/or Sneezing?*

YES

NOT SURE

Pet 2 currently on Flea / Tick Preventative?

YES

NOT SURE

Pet 2 If "YES" to Flea / Tick, which brand?

Pet 2 Currently on Heartworm Preventative?

YES

NOT SURE

Pet 2 If "YES" to Heartworm, which brand?

Is Pet 2 on any other medications, currently?

Pet 3

Have we seen Pet 3 before?

Yes

Pet 3 Name*

Species 3*

Breed Pet 3*

Gender / Fixed Pet 3*

Color Pet 3*

Age Pet 3*

Pet 3 Current diet, amount fed, & frequency*

Pet 3 Last Veterinary Visit*

MM slash DD slash YYYY

Pet 3 Rabies Vaccine Current?*

YES

NOT SURE

Pet 3 have known allergies? Please list, or state "N/A".*

Pet 3 Eating & Drinking normally?*

YES

NOT SURE

Pet 3 Coughing and/or Sneezing?*

YES

NOT SURE

Pet 3: Currently on Flea / Tick Preventative?

YES

NOT SURE

Pet 3 If "YES" to Flea / Tick, which brand?

Pet 3 Currently on Heartworm Preventative?

YES

NOT SURE

Pet 3 If "YES" to Heartworm, which brand?

Is Pet 3 on any other medications, currently?

Why Am I Here Today?

Arthritis

Arthritis (or showing signs of arthritis)

Please check all that apply.

Lagging behind on walks

Licking of the affected joint(s)

Limping / lameness

Pain or stiffness when getting up or down

Personality change (aggression when normally good-natured)

Reluctance to walk, climb stairs, jump or play.

Yelping when touched

Bladder / Urinary Tract

Bladder / Urinary Tract

Please check all that apply.

Bloody urination

Crying out or whining while urinating

Inappropriate urination (accidents in the house)

Increased frequency of urination

Licking genitals

Offensive (strong) odor in urine

painful urination

Straining to urinate

Urgency of urination

Urine dribbling

Dental Disease

Dental Disease

Please check all that apply.

Bad breath

Bleeding or red gums

Blood in water bowl or on chew toys

Bloody saliva

Bumps or lumps in the mouth

Drooling

Loose teeth

Painful

Problem picking up food

Refusing to eat

Yellow-brown tarter on teeth

Digestive Problems

Digestive Problems

Please check all that apply.

Blood or mucus in the stool

Constipation

Diarrhea

Excess gas or flatulance

Loss of appetite

Painful stomach area

Straining when passing stools

Vomiting

Ear

Please check all that apply.

Crusting or scabs in ear

Dark discharge from ear

Head shaking

Infection

Itchiness

Odor

Painful ear

Redness in the ear canal

Scratching at the affected ear

Swollen ear flap (HEMATOMA)

Eye

Eye

Please check all that apply.

Dilated pupils

Excessive blinking

Excessive tearing

Eye bulging

Eye cloudiness

Eye inflammation

Eye irritation

Eye pain

Eye redness

Gooey eye discharge

Inflammation around eye

Lump on eyelid

Pawing at the eyes

Squinting

Prescription Refill

Prescription Refill

Tell us what you need

Skin Disease

Skin Disease

Please check all that apply.

Allergy

Allergic dermatitis

Bumps / Lumps

Hair loss

Hot spots

Infection

Itching

Masses / tumors

Skin, painful to the touch

Weight Change

Weight Change

Change in weight?

Vaccinations

Vaccinations

Check applicable age.

Adult Dog (1-yr or older)

Puppy (select age range below)

Adult Cat (1-yr or older)

Kitten (select age range below)

Puppy Age (weeks)

How old is your puppy? (weeks)

Kitten Age (weeks)

How old is your kitten? (weeks)

Heartworm Test

Heartworm Test

Heartworm Preventative

Heartworm Preventative

Flea / Tick Preventative

Flea / Tick Preventative

Other, Not Listed

Other, Not Listed

Other important issues to discuss today:

Follow-up/Recheck

Follow-up/Recheck

Simple description of what your past appointment about.