Patient History Form in Martinez, CA - Martinez Animal Hospital

Client's Name:*

What is your pet's name:*

Species*

Is this a recheck appointment?*

Yes
No

What concerns you about your pet today?*

How long has this problem been going on?*

Are there any other problems?*

Yes
No

Past History:*

General Appearance / Attitude*

Any Behavior Issues?*

Yes
No

Explain Below:*

Any Allergies (that you know of?)*

Yes
No

Explain Below:*

Any history of seizures?*

Yes
No

Explain Below:*

Any past surgeries?*

Yes
No

Explain Below:*

Is your pet Indoor? Outdoor? Both?*

Indoor
Outdoor
Both

Does your pet have any access or exposure to open space? Tick exposure?*

Yes
No

Any potential exposure to toxins (insecticides, poisons, antifreeze?)*

Yes
No

Is there any vomiting?*

Yes
No

How Long?*

Is there any diarrhea?*

Yes
No

Is there any coughing?*

Yes
No

How Long?*

Is there any sneezing?*

Yes
No

Is your pet eating?*

Yes
No

Is your pet drinking?*

Yes
No

Is your pet urinating normally?*

Yes
No

For how long has this been an issue?*

Bowel movements normal?*

Yes
No

For how long has this been an issue?*

If your patient is a cat, Is cat using litter box appropriately?*

Yes
No
N/a

If your patient uses a litter box, what kind of litter do you use?*

Please say "N/A" if not applicable

What is your pet’s diet including name brand and how much do you feed per day? Grain Free Diet?*

Is your pet currently taking any medication?*

Yes
No

What medication and dosage are you giving? Please list at home medication routine for the Doctor to review. BE SPECIFIC!*

Was the medication given today?*

Is your pet on consistent flea control?*

Yes
No

Is your pet micro chipped?*

Yes
No

Is your pet spayed or neutered or no?*

Yes
No

Is your pet current on its rabies vaccination?*

Yes
No

Other vaccinations?*

Yes
No

Any history of vaccine reactions?*

Yes
No

Please Explain*

Has your pet had a fecal analysis in the last 6 months?*

Yes
No

Is your pet on consistent heartworm prevention?*

Yes
No

What brand of flea prevention do you use? (Please do not put "you have it on file!" Be specific!)*

What brand of tick prevention do you use? (Please do not put "you have it on file!" Be specific!)*

What brand of heartworm prevention do you use? (Please do not put "you have it on file!" Be specific!)*

Are there other pets at home?*

Yes
No

What kind?*

What insurance provider do you have for your pet?*

I authorize Martinez Animal Hospital to charge up to this amount in case I am unavailable for contact*

Please enter maximum $ value

In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked.*

Alternate Phone*

LATE ARRIVAL POLICY*

I agree to the late arrival to appointment policy.

IF YOU ARE 10+ MINUTES LATE TO YOUR APPOINTMENT, IT IS UP TO OUR DISCRETION IF WE CAN STILL TAKE YOUR APPOINTMENT. A $10 LATE ARRIVAL FEE WILL APPLY.

CANCELLATION/NO SHOW POLICY*

I agree to the cancellation/ no show policy.

WE REQUIRE 24 HOUR NOTICE FOR RESCHEDULING AND CANCELLING APPOINTMENTS. IF YOU DO NOT PROVIDE US 24 HOUR NOTICE, YOU WILL BE CHARGED A MISSED APPOINTMENT FEE. BY CHECKING THIS BOX, YOU UNDERSTAND THAT IF YOU DO NOT GIVE US APPROPRIATE CANCELLATION NOTICE, YOU MAY BE ASKED TO PRE-PAY FOR YOUR NEXT APPOINTMENT.

Signature*

Date

Consent

I agree to the privacy policy.