Welcome!

We are excited to meet you during your first appointment!

To ensure your information is correctly logged in our system to secure your appointment, please fill out our New Client Intake Form.

New Client Intake

"*" 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.

For your protection, and that of others, pets should be properly restrained by a leash or carrier upon arrival.

If you must cancel an appointment we ask for 24 hours notice. For surgical appointments we ask for 48 hour cancellation notice. A late cancellation or frequent cancellations may result in a fee being applied to your account.

Avenue Animal Hospital 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 accept cash, debit, or credit cards. We also offer Care Credit and Scratch Pay financing to help make the highest quality care accessible to all our patients.

We will gladly prepare a written treatment plan of fees if you desire. Please ask for your written treatment plan.

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.

Do we have permission to share your pet's image and story on social media?*

Yes

Owner's Signature*

Date*

MM slash DD slash YYYY

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New Client Intake

Canine & Feline Patient History Form

Client Information

Patient Information

Diet and Environment

Review of Signs

Past History

Office Policies

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Get in touch

708-532-3866

708-532-3866

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