"*" indicates required fields

Canine & Feline Patient History Form

Date*

MM slash DD slash YYYY

Client Information

Owner First Name*

Owner Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email*

Emergency Contact

If you were referred by a client, please tell us who so we may thank them!

Are you an active duty military member? Show a staff member you ID to receive a military discount.

Patient Information

Patient Name*

Breed*

Gender*

Male

Female

Color*

Date of Birth/Approximate Age*

Is your pet spayed/neutered?*

Yes

Unsure

Has your pet been to another veterinarian?*

Yes

If so, where?*

Diet and Environment

What food does patient currently eat?*

Amount & Frequency?*

Is your pet on any dietary supplements?*

Yes

If so, what kind and what dosage?*

Does your pet consume table food?*

Yes

Is your pet primarily indoor or outdoor?*

Are there any other animals in the household?*

Yes

Does you have your pet groomed or boarded outside of your home?*

Yes

If so, how often?*

Do you travel outside of your local area with your pet?*

Yes

If so, where?*

Review of Signs

Has your pet exhibited any attitude or behavior change?*

Yes

Has your pet ever had seizures?*

Yes

Any recent appetite changes?*

Yes

Does your pet have any exercise intolerance?*

Yes

Has your pet had changes in urination?*

Yes

Any recent weight changes?*

Yes

Has your pet been vomiting?*

Yes

Has your pet had any diarrhea?*

Yes

Has your pet been coughing?*

Yes

Has your pet been sneezing?*

Yes

Has your pet exhibited any signs of lameness?*

Yes

Has your pet been itching?*

Yes

Does your pet have difficulty rising after lying done?*

Yes

Has your pet had any recent hair loss?*

Yes

Does your pet have any growths on body?*

Yes

Location*

Does your pet have any discharge from nose, eyes, vulva, etc?*

Yes

Past History

Has your pet had any prior illnesses, accidents, or surgeries?*

Yes

Is your pet aggressive or fearful around strangers?*

Yes

Do you ever give your pet over-the-counter medications (i.e. Aspirin, Tylenol, Advil, etc)*

Yes

Is your pet on heartworm, flea/tick preventatives, or any other medication?*

Yes

Does your pet have any known allergies to any medications?*

Yes

If yes, please list*

Has your pet ever had a reaction to any vaccines?*

Yes

If yes, please list and explain below*

Office Policies

To allow for ample time for all patients and surgical procedures, Avenue Animal Hospital operates by appointment. We also are available to see Walk-Ins and Emergencies, however, these services may be subject to a higher fee schedule. As such, we request all our clients be on time for scheduled appointments and procedures.

For your convenience, we can accept drop offs for exams, surgeries, etc. To ensure that we have the space to accommodate your pet, we request you make arrangements for this in advance. There may be a ward occupancy fee associated with drop off cases.

Prior to arriving to your appointment:

Please make sure your pets are properly restrained by a leash or carrier upon arrival.
We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead with enough notice and we will have your order ready when you arrive.
We will gladly prepare a written treatment plan of fees if you desire. Just ask!
If you must cancel an appointment, we ask for 24 hour notice. For surgical appointments we ask for 48-hour cancellation notice.
Please review our hospital policies below.

Appointment Confirmation Policy:

When you schedule an appointment, an email, text, or app reminder will be delivered to you to confirm your scheduled appointment. We ask that you confirm or cancel the appointment either by text, email, or call us within 24 hours of the scheduled appointment time as this will keep your spot reserved. Confirmation is a requirement to retain your scheduled appointment spot. If you do not confirm your appointment, the appointment slot will be given to the next person on the waitlist, and you will have to reschedule for a different date. If you are calling after hours, please leave a detailed message with your information, your pet’s information, and the date and time of the appointment that you are confirming or canceling.

Late Policy/Procedure:

At 5 minutes past your confirmed scheduled appointment time, we will send a courtesy text or phone call, informing you that you are late and seeing if you are on your way to the hospital.

At 10 minutes past your confirmed scheduled appointment time, we will send a final text or phone call, informing you that you are 10 minutes late and the appointment is now considered a No Show. Please refer to the No Call No Show policy below.

No Show Policy:

In the event of a missed confirmed appointment or tardiness exceeding 10 minutes for non-surgical appointments, a non-refundable Exam Fee will be incurred and applied to your account. This includes all technician-based appointments. Prior to scheduling another appointment, this fee must be settled.

If you do not show up for your confirmed surgical scheduled appointment, there will be a $150.00 non-refundable fee on your account that will need to be paid before scheduling another appointment.

Appointments and Surgeries:

We strive to keep to our schedule as best as we can, while allowing for ample time and attention that is needed for each pet. Therefore, we expect our clients to arrive for their scheduled appointment on time.

Out of respect for all parties involved, we request that if something unexpected happens and you are running behind, please call the clinic and let us know. Depending on our existing schedule, your doctor will determine if we will still be able to see your pet if we need to reschedule the appointment. This will all depend on how late you may arrive for the appointment.

Payment Policy:

All payments are due at the time of services. Please make sure to discuss any type of financial concerns PRIOR to services and treatments.

We accept all major credit/debit cards, checks, and/or cash.

We also offer Care Credit and Scratch Pay financing to help make the highest quality care accessible to all our patients

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal.

I understand that payment is ALWAYS DUE IN FULL at time of service. I recognize that financial concerns should be discussed PRIOR to exam and treatment.

We love social media! Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? [Your name and personal information will never be shared.]*

Yes

Owner's Signature*

Date*

MM slash DD slash YYYY

This field is for validation purposes and should be left unchanged.

New Client Intake