Pet Check-in Form Use this form if you already have an appointment. If you need to MAKE AN APPOINTMENT, click here. APPOINTMENT CHECK IN Please complete and submit this form BEFORE your appointment time, to ensure our staff is ready when your pet arrives. Are you a current client? Have you been here before?* Yes No Appointment Type?* Wait Scheduled Drop-Off Date of Appointment* What is the scheduled date of your appointment? MM slash DD slash YYYY What time is your appointment scheduled for?* : Hours Minutes AMPM AM/PM Your Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Email* Mobile Phone* Pet #1 Pet Name* Species (pet 1)* DogCat Breed* Color* Age* Gender / Fixed* MaleFemaleNeutered MaleSpayed Female Current diet, amount fed, & frequency* Last Veterinary Visit* MM slash DD slash YYYY Rabies Vaccine Current?* YES NO NOT SURE Pet have known allergies? Please list, or state "N/A".* Eating normally?* YES NO NOT SURE Drinking normally?* YES NO NOT SURE Coughing?* YES NO NOT SURE Sneezing?* YES NO NOT SURE Currently on Heartworm Preventative?* YES NO NOT SURE If "YES" to Heartworm, which brand? Currently on Flea / Tick Preventative?* YES NO NOT SURE If "YES" to Flea / Tick, which brand? Current meds or supplements pet is taking:* If “none”, please indicate so. Why Am I Here Today? Pet 1 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 Pet 1 Bladder 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 Pet 1 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 Pet 1 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 Pet 1 Ear 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) Pet 1 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 Pet 1 Prescription Refill Prescription Refill Tell us what you need Pet 1 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 Pet 1 Weight Change Weight Change Change in weight? Pet 1 Vaccinations Vaccinations Check applicable age. Pet 1 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) Pet 1 Heartworm Test Heartworm Test Pet 1 Heartworm Preventative Heartworm Preventative Pet 1 Flea Tick Flea / Tick Preventative Pet 1 Other Other, Not Listed Other important issues to discuss today: Did you bring another pet? Yes No Pet #2 Pet 2 Name* Species (pet 2)* DogCat Breed* Color* Age* Gender / Fixed* MaleFemaleNeutered MaleSpayed Female Current diet, amount fed, & frequency* Last Veterinary Visit* MM slash DD slash YYYY Rabies Vaccine Current?* YES NO NOT SURE Pet have known allergies? Please list, or state "N/A".* Eating normally?* YES NO NOT SURE Drinking normally?* YES NO NOT SURE Coughing?* YES NO NOT SURE Sneezing?* YES NO NOT SURE Currently on Heartworm Preventative? (pet 2)* YES NO NOT SURE If "YES" to Heartworm, which brand? Currently on Flea / Tick Preventative? (pet 2)* YES NO NOT SURE If "YES" to Flea / Tick, which brand? Current meds or supplements pet is taking: If “none”, please indicate so. Why Am I Here Today? (Pet 2) Pet 2 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 Pet 2 Bladder 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 Pet 2 Dental 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 Pet 2 Digestive 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 Pet 2 Ear 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) Pet 2 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 Pet 2 Prescription Prescription Refill Tell us what you need Pet 2 Skin 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 Pet 2 Weight Change Weight Change Change in weight? Pet 2 Vaccinations Vaccinations Check applicable age. (pet 2) 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) Pet 2 Heartworm Test Heartworm Test Pet 2 Heartworm Preventative Heartworm Preventative Pet 2 Flea Tick Flea / Tick Preventative Pet 2 Other Other, Not Listed Other important issues to discuss today: This may sound crazy, but did you bring a 3rd pet? Yes No Pet #3 Pet 3 Name* Species (pet 3)* DogCat Breed* Color* Age* Gender / Fixed* MaleFemaleNeutered MaleSpayed Female Current diet, amount fed, & frequency* Last Veterinary Visit* MM slash DD slash YYYY Rabies Vaccine Current?* YES NO NOT SURE Pet have known allergies? Please list, or state "N/A".* Eating normally?* YES NO NOT SURE Drinking normally?* YES NO NOT SURE Coughing?* YES NO NOT SURE Sneezing?* YES NO NOT SURE Currently on Heartworm Preventative? (pet 3)* YES NO NOT SURE If "YES" to Heartworm, which brand? Currently on Flea / Tick Preventative? (pet 3)* YES NO NOT SURE If "YES" to Flea / Tick, which brand? Current meds or supplements pet is taking: If “none”, please indicate so. Why Am I Here Today? (Pet 3) Pet 3 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 Pet 3 Bladder 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 Pet 3 Dental 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 Pet 3 Digestive 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 Pet 3 Ear 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) Pet 3 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 Tell us what you need Pet 3 Prescription Prescription Refill Pet 3 Skin 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 Pet 3 Weight Change Weight Change Change in weight? Pet 3 Vaccinations Vaccinations Check applicable age. (pet 3) 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) Pet 3 Heartworm Test Heartworm Test Pet 3 Heartworm Preventative Heartworm Preventative Pet 3 Flea Tick Flea / Tick Preventative Pet 3 Other Other, Not Listed Other important issues to discuss today: Bruh… you do NOT have a 4th pet… right? Yes No You qualify for a nickname. You qualify for a nickname. Referral Would you like a $20 credit added to your account? Thank you for being a great client. We’ve enjoyed serving you. If you’re happy with the service you’ve received from our dedicated doctors and staff, would you like to refer someone? When they come in, you’ll get a $20 credit to your account and they’ll receive $20 off their first visit. Yes No Referral Name Who would you like to refer and save them $20 on their next visit, while earning yourself $20 credit? First Last Referral Email What is their email address? Δ