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vetxpress.colonialheights@gmail.com
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Patient Intake Form
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Patient Intake Form
Save time during your next appointment! Complete your Patient Intake Form online from any device at any time before your visit.
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Client Information
Your Full Name
*
First
Last
Email
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Cellular Number
Patient Information
Pet's Name
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Pet's Birth Date/Age
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Species
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Breed
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Color
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Weight
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Sex
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Male
Male Neutered
Female
Female Spayed
Previous Veterinarian
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Previous Medical History
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Does your pet have a microchip identification?
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Yes
No
History Information
Concern for Today’s visit
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When did your pet last eat?
What diet are your currently feeding your pet?
Any coughing or sneezing?
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Yes
No
If yes, how often?
Any vomiting or diarrhea?
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Yes
No
If yes, how often and the consistency of the stool / vomitus?
Is your pet taking heartworm prevention?
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Yes
No
What product and when was it last given?
Is your pet taking flea and tick prevention?
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Yes
No
What product and when was it last given?
Is your pet currently taking any medications?
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Yes
No
Please list all medication your pet is currently on:
Do you need any refills?
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Yes
No
Which medications do you need refills for?
After examination by the doctor, may we proceed with tests and/or treatments?
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Proceed with tests and/or treatments deemed necessary for the best care
Call me for approval before completing any services to my pet.
If the vetXpress staff finds a live flea on your pet, we will administer flea control to your pet at your expense.
*
I have read and understand
How did you hear about us?
Referral from a friend
Our Website
Facebook
Newspaper
Other
Please Note:
• If your pet is being dropped off for an appointment, we require an 60% deposit during check in and the remained to be paid upon release of you pet from the hospital.
• We accept cash, VISA, MASTERCARD, and DISCOVER.
•We accept checks only from established clients.
• We must have a copy of a valid driver’s license on file for each client.
• We accept CareCredit.
• All fees are due at the time services are rendered.
Medical Records
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You can upload up to 10 files.
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I understand and agree to the above terms and verify that all information that I have provided is correct and current.
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