Client Intake FormClient Intake FormName(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)Primary Care 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 MaintainAppetite Good Poor NoneIs your pet current on vaccines? Yes NoLast Vaccines MM slash DD slash YYYY Is your pet heartworm positive? Yes NoType of Heartworm Prevention – BrandIs your pet current on heartworm prevention? Yes NoLast given? MM slash DD slash YYYY Flea Prevention Topical OralIs 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 NegativeToxin 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)Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHAΔ
