Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care. It would be extremely helpful to have the information the day prior to your appointment if possible. Thank you!

Pet's Name *

Your Name *

First

Last

Email *

Date of Appointment

Instructions

Clients are allowed in the building for appointments, but if possible we ask that only 2 people come in with their pets. If you have a large family we can provide Curbside care for your pet to help stay distanced in the small rooms. We ask that you wear a mask if you are not fully vaccinated against Covid-19 and our team will do the same. If you would like to stay in your car, please call in when you arrive.

If you have been sick please send your pet with someone else or do not enter our facility, but elect for curbside care to try and protect our team and others around you.

Where can we call you while your pet is here? *

I would like the following vaccines administered if due

DOG - Distemper - core for all dogs
DOG - Leptospirosis - core for all dogs
DOG - Lyme Disese - optional for dogs with tick exposure
DOG- Bordetella - optional for dogs with exposure to other dogs
DOG - Influenza - optional for dogs with exposure to other dogs
CAT - Distemper - core for all cats
CAT - Feline Leukemia - optional for cats who are outside
DOG or CAT - Rabies: core for all pets
No Vaccines Today

My pet's vaccines were administered last by

Brooklyn Road Veterinary Clinic
I Am Not Sure Where
Other

If other, please specify

My pet eats

If other, please specify

Brand of Pet Food

If prescription diet, what formulation?

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)

Does your pet have any allergies or reactions?

If yes, please specify

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:

Has your pet had any:

New lumps or bumps
Behavior changes
Changes in mobility

My pet's appetite is:

My pet's thirst level is:

My pet's activity level is:

My pet's urination is:

When Was Your Pet's Last Dose of Heartworm Preventative?

Date Given (Please type N/A if not on a preventative)

What Heartworm Prevention Do You Use?

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

What Type of Flea/Tick Prevention Do You Use?

Is Your Pet:

If other, please specify

Are There Other Pet's In The Home

Yes
No
Farm Animals

The following questions help us to assess the lifestyle of your pet to give the best advice on needed protection.

Does Your Pet

Does Your Pet Have A Microchip?

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?

Are there pictures or video that would help us with our exam today?

Click or drag a file to this area to upload.

Is There Anything Else You Would Like To Discuss Today?

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone *

Initial

For your convenience we keep several medications in our office. You may choose to purchase them here, or we have an online store that will ship them directly to you. If you would like a written prescription one will be provided, but you are responsible for making sure the pharmacy is safe and legal. We will not call, email or fax prescriptions, (you must pick them up from our office) due to previous mistakes made at pharmacies *

Initial

I understand that my pet must be examined annually to be considered an active patient and to receive prescriptions. There may also be monitoring blood work or urine required for some medications. Refills will not be provided beyond the due date for rechecks *

Initial

I understand that the Brooklyn Road Veterinary Clinic advises use of parasite prevention every 30 days throughout the entire year to protect my pet and my family from any contagious parasites. I will not hold Brooklyn Road Vet Clinic responsible for my pet or my family becoming infected if I choose not to provide that protection *

Initial

Social Media Permission: Brooklyn Road Vet Clinic has my permission to take photographs and use them in print or digital media *

Yes
No

Signature *

Wellness Check-in Form

Wellness Check-in

Instructions

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