Veterinarian Patient Intake Form

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Veterinarian Patient Intake Form

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Last updated July 19th, 2023

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A veterinarian patient intake form is used by a veterinary clinic or animal hospital to gather information about new clients and their pets. Typically, it will ask for information such as the pet’s name, breed, medical background, and any present issues or symptoms. The form aids veterinarians in understanding the animal’s history, determining its healthcare requirements, and delivering the best possible treatment while helping ensure the pet’s and staff’s safety.

Veterinary Clinic vs. Animal Hospital

Though similar, some key differences exist between a veterinary (vet) clinic and an animal hospital. Generally, vet clinics are smaller, offer more limited services, and are usually equipped to handle minor surgeries, preventative medicine, and pet wellness checkups. Animal hospitals are more extensive facilities that can keep pets overnight and handle more complex medical procedures.

CONTENTS

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: ____________________

Essential Client Information

All intake forms should include the following information to ensure that medical professionals provide the best possible care.

Contact Information

The client should include their name, address, email, and phone number in case the vet needs to contact them at any time. They should also have an emergency contact in the event of a medical emergency when the primary client is unavailable.

Pet Background Information

In order for the vet to properly prepare for the animal, they should be informed of the pets:

  • 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, current medications, and current symptoms the pet may be suffering from. The pet’s current diet and status of their appetite should also be collected. If the pet was previously treated at another clinic or hospital, the client should provide that information in case the new veterinarian needs to speak with them.