Essential Client Information
The below info should be inputted into the intake form by each new client to facilitate the care of their animals.
Contact Information
The client should include their name, address, email, and phone number for the vet’s records. They should also have an emergency contact in the event of a medical emergency.
Pet Background Information
In order for the veterinarian to prepare for the animal, they should be informed of the pet’s:
- Name, species, and breed.
- Gender and whether they have been neutered or spayed.
- Color and age.
- Exposure to the outdoors.
- Travel history.
Pet Medical Information
Clients will be asked to provide the pet’s medical history, including any vaccinations, allergies, medications, and symptoms. If the pet was previously treated at another clinic or hospital, the client should inform the veterinarian.
Sample
Download: PDF, Word (.docx), OpenDocument
VETERINARIAN PATIENT INTAKE FORM
DISCLAIMER: Thank you for your interest in being a patient of [VETERINARIAN NAME]. Information collected about new patients is confidential and will be treated accordingly.
CLIENT INFORMATION |
Name: _____________________
Street Address: ______________________________
City: _____________________ State: _____________________ Zip Code: ________
E-Mail: _____________________ Phone: _____________________
PET INFORMATION |
Pet Name: _____________________
Species: _____________________ Breed: _____________________
Color: _____________ Age: ____________
Gender: ☐ Male ☐ Female ☐ Unknown
Neutered/Spayed: ☐ Yes ☐ No ☐ Unknown
Exposure to outdoors: ☐ Indoor Only ☐ Outdoor Exposure
MEDICAL INFORMATION |
Name of previous hospital: _____________________ Phone: __________________
List any known vaccinations: _________________________________________
List any current allergies: ____________________________________________
List any current medications: _________________________________________
– Do you need a refill of any medications: ☐ Yes ☐ No
List any current symptoms: _________________________________________
– Are the symptoms: ☐ Improving ☐ Worsening ☐ Stable
– When did you first notice the symptoms: ______________________________
Has your pet been sick previously: ☐ Yes ☐ No
– Describe the issue/treatment: _________________________________________
Describe the pet’s current diet: _________________________________________
– Has the appetite: ☐ Increased ☐ Decreased ☐ Unchanged
SIGNATURE |
Signature: _________________________ Date: ___________
Printed Name: ____________________