Veterinarian Patient Intake Form

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A veterinarian patient intake form is used by a veterinary clinic or animal hospital to gather information about clients and their pets. It records the pet’s name, breed, medical background, and any present issues or symptoms. This form is the first step in making sure a vet can provide the care necessary to promote the health and wellbeing of each client’s pet.

Veterinarian Patient Intake Form

A veterinarian patient intake form is used by a veterinary clinic or animal hospital to gather information about clients and their pets. It records the pet’s name, breed, medical background, and any present issues or symptoms. This form is the first step in making sure a vet can provide the care necessary to promote the health and wellbeing of each client’s pet.

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Last updated October 16th, 2024

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A veterinarian patient intake form is used by a veterinary clinic or animal hospital to gather information about clients and their pets. It records the pet’s name, breed, medical background, and any present issues or symptoms. This form is the first step in making sure a vet can provide the care necessary to promote the health and wellbeing of each client’s pet.

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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

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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: ____________________