Client Intake Form Client Intake Form Name(Required) First Last Address(Required) 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 Phone(Required)Email(Required) Patient InformationPet Name(Required)Species (Dog/Cat)(Required)Breed(Required)Gender (M/F)Spayed/Neutered?(Required)Please selectYesNoAgeIf female and not spayed, when was last heat cycle MM slash DD slash YYYY ColorReason for visit today:(Required)Your Family VeterinarianVeterinary Hospital(Required)DoctorPatient HistoryAny previous illnesses or surgeries:Any allergies to medications, vaccines, or food: (Y/N)If yes, please list allergies:Any diet changes? (Y/N)Diet – Current food:Any diet changes? (Y/N)Weight Loss Gain Maintain Appetite Good Poor None Is your pet current on vaccines? Yes No Last Vaccines MM slash DD slash YYYY Is your pet on any regular medications?(Required) Yes No Please list all medications and the last time they were given:(Required)Is your pet heartworm positive? Yes No Type of Heartworm Prevention – BrandIs your pet current on heartworm prevention? Yes No Last given? MM slash DD slash YYYY Flea Prevention Topical Oral Is your pet primarily indoors, outdoors, or both? Indoors Outdoors Both ***Felines Only***Has your pet been FIV/FeLV tested? (Y/N)Is your pet primarily indoors, outdoors, or both? Positive Negative Toxin ExposureHas your pet potentially been exposed to any plants, toxins, or human medications? (Y/N)If Yes, please listAre there other pets in the household, and if so please note their health status.***RESCUES ONLY***Name of Rescue GroupContact personPhoneConsent(Required) I attest, to the best of my abilities, all statements above are complete and correct. I understand the emergency room evaluation fee of $165. Exam fee does not include any treatment, diagnostic testing, or medications. Payment is due at the time of service.(Required)Consent(Required) I authorize Pearland 288 Animal Emergency Clinic to release my pets’ records to my veterinarian and/or insurance company.(Required)I consent to the use of photograph(s) of my property by Pearland 288 Animal Emergency Clinic for promotional and advertising purposes. I waive all rights and fees for Pearland 288 Animal Emergency Clinic to use said photo(s) for ads, brochures, website, social media, or any other promotional use. I also understand that there is no limitation in terms of time for Pearland 288 Animal Emergency Clinic to use photo(s). It is agreed by Pearland 288 Animal Emergency Clinic that neither the client's name nor address will be disclosed in connection with any promotional and advertising purposes unless expressly consented to by the owner. Yes No Signature(Required)Date(Required) MM slash DD slash YYYY Δ
