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 on any regular medications?(Required) Yes NoPlease list all medications and the last time they were given:(Required)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
