Pet Check-in Form

Use this form if you already have an appointment.
If you need to MAKE AN APPOINTMENT, click here.

APPOINTMENT CHECK IN

Please complete and submit this form BEFORE your appointment time, to ensure our staff is ready when your pet arrives.

• Are you a current client? Have you been here before?*
  • Yes
  • No
• Appointment Type?*
  Medical Patients Please plan to drop off all medical patients and pick up later. Wellness Patients (Vaccinations Heartworm test etc.) We prefer that you wait on these patients, please confirm with receptionist or technician if drop off is necessary.
  • Wait in Car
  • Appointment in Exam Room
  • Scheduled Drop-Off
• Vehicle description:*
  Make, model, color...
• Date of Appointment*
  What is the scheduled date of your appointment?
  MM slash DD slash YYYY
• What time is your appointment scheduled for?*
  : Hours

  Minutes

  AM PM
• Your Name*
  First Last
• Address*
  Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Primary Email*
• Mobile Phone*

• Pet #1

• Pet Name*
• Species (pet 1)*
  DogCat
• Breed*
• Color*
• Age*
• Gender / Fixed*
  MaleFemaleNeutered MaleSpayed Female
• Current diet, amount fed, & frequency*
• Last Veterinary Visit*
  MM slash DD slash YYYY
• Rabies Vaccine Current?*
  • YES
  • NO
  • NOT SURE
• Pet have known allergies? Please list, or state "N/A".*
• Eating normally?*
  • YES
  • NO
  • NOT SURE
• Drinking normally?*
  • YES
  • NO
  • NOT SURE
• Coughing?*
  • YES
  • NO
  • NOT SURE
• Sneezing?*
  • YES
  • NO
  • NOT SURE
• Currently on Heartworm Preventative?*
  • YES
  • NO
  • NOT SURE
• If "YES" to Heartworm, which brand?
• Currently on Flea / Tick Preventative?*
  • YES
  • NO
  • NOT SURE
• If "YES" to Flea / Tick, which brand?
• Current meds or supplements pet is taking:*
  If "none", please indicate so.

• Why Am I Here Today?

• Pet 1 Arthritis
  • Arthritis (or showing signs of arthritis)
• Please check all that apply.
  • Lagging behind on walks
  • Licking of the affected joint(s)
  • Limping / lameness
  • Pain or stiffness when getting up or down
  • Personality change (aggression when normally good-natured)
  • Reluctance to walk, climb stairs, jump or play.
  • Yelping when touched
• Pet 1 Bladder
  • Bladder / Urinary Tract
• Please check all that apply.
  • Bloody urination
  • Crying out or whining while urinating
  • Inappropriate urination (accidents in the house)
  • Increased frequency of urination
  • Licking genitals
  • Offensive (strong) odor in urine
  • painful urination
  • Straining to urinate
  • Urgency of urination
  • Urine dribbling
• Pet 1 Dental Disease
  • Dental Disease
• Please check all that apply.
  • Bad breath
  • Bleeding or red gums
  • Blood in water bowl or on chew toys
  • Bloody saliva
  • Bumps or lumps in the mouth
  • Drooling
  • Loose teeth
  • Painful
  • Problem picking up food
  • Refusing to eat
  • Yellow-brown tarter on teeth
• Pet 1 Digestive Problems
  • Digestive Problems
• Please check all that apply.
  • Blood or mucus in the stool
  • Constipation
  • Diarrhea
  • Excess gas or flatulance
  • Loss of appetite
  • Painful stomach area
  • Straining when passing stools
  • Vomiting
• Pet 1 Ear
  • Ear
• Please check all that apply.
  • Crusting or scabs in ear
  • Dark discharge from ear
  • Head shaking
  • Infection
  • Itchiness
  • Odor
  • Painful ear
  • Redness in the ear canal
  • Scratching at the affected ear
  • Swollen ear flap (HEMATOMA)
• Pet 1 Eye
  • Eye
• Please check all that apply.
  • Dilated pupils
  • Excessive blinking
  • Excessive tearing
  • Eye bulging
  • Eye cloudiness
  • Eye inflammation
  • Eye irritation
  • Eye pain
  • Eye redness
  • Gooey eye discharge
  • Inflammation around eye
  • Lump on eyelid
  • Pawing at the eyes
  • Squinting
• Pet 1 Prescription Refill
  • Prescription Refill
• Tell us what you need
• Pet 1 Skin Disease
  • Skin Disease
• Please check all that apply.
  • Allergy
  • Allergic dermatitis
  • Bumps / Lumps
  • Hair loss
  • Hot spots
  • Infection
  • Itching
  • Masses / tumors
  • Skin, painful to the touch
• Pet 1 Weight Change
  • Weight Change
• Change in weight?
• Pet 1 Vaccinations
  • Vaccinations
• Check applicable age. Pet 1
  • Adult Dog (1-yr or older)
  • Puppy (select age range below)
  • Adult Cat (1-yr or older)
  • Kitten (select age range below)
• Puppy Age (weeks)*
  How old is your puppy? (weeks)
• Kitten Age (weeks)*
  How old is your kitten? (weeks)
• Pet 1 Heartworm Test
  • Heartworm Test
• Pet 1 Heartworm Preventative
  • Heartworm Preventative
• Pet 1 Flea Tick
  • Flea / Tick Preventative
• Pet 1 Other
  • Other, Not Listed
• Other important issues to discuss today:
• Did you bring another pet?
  • Yes
  • No

• Pet #2

• Pet 2 Name*
• Species (pet 2)*
  DogCat
• Breed*
• Color*
• Age*
• Gender / Fixed*
  MaleFemaleNeutered MaleSpayed Female
• Current diet, amount fed, & frequency*
• Last Veterinary Visit*
  MM slash DD slash YYYY
• Rabies Vaccine Current?*
  • YES
  • NO
  • NOT SURE
• Pet have known allergies? Please list, or state "N/A".*
• Eating normally?*
  • YES
  • NO
  • NOT SURE
• Drinking normally?*
  • YES
  • NO
  • NOT SURE
• Coughing?*
  • YES
  • NO
  • NOT SURE
• Sneezing?*
  • YES
  • NO
  • NOT SURE
• Currently on Heartworm Preventative? (pet 2)*
  • YES
  • NO
  • NOT SURE
• If "YES" to Heartworm, which brand?
• Currently on Flea / Tick Preventative? (pet 2)*
  • YES
  • NO
  • NOT SURE
• If "YES" to Flea / Tick, which brand?
• Current meds or supplements pet is taking:
  If "none", please indicate so.

• Why Am I Here Today? (Pet 2)

• Pet 2 Arthritis
  • Arthritis (or showing signs of arthritis)
• Please check all that apply.
  • Lagging behind on walks
  • Licking of the affected joint(s)
  • Limping / lameness
  • Pain or stiffness when getting up or down
  • Personality change (aggression when normally good-natured)
  • Reluctance to walk, climb stairs, jump or play.
  • Yelping when touched
• Pet 2 Bladder
  • Bladder / Urinary Tract
• Please check all that apply.
  • Bloody urination
  • Crying out or whining while urinating
  • Inappropriate urination (accidents in the house)
  • Increased frequency of urination
  • Licking genitals
  • Offensive (strong) odor in urine
  • painful urination
  • Straining to urinate
  • Urgency of urination
  • Urine dribbling
• Pet 2 Dental
  • Dental Disease
• Please check all that apply.
  • Bad breath
  • Bleeding or red gums
  • Blood in water bowl or on chew toys
  • Bloody saliva
  • Bumps or lumps in the mouth
  • Drooling
  • Loose teeth
  • Painful
  • Problem picking up food
  • Refusing to eat
  • Yellow-brown tarter on teeth
• Pet 2 Digestive
  • Digestive Problems
• Please check all that apply.
  • Blood or mucus in the stool
  • Constipation
  • Diarrhea
  • Excess gas or flatulance
  • Loss of appetite
  • Painful stomach area
  • Straining when passing stools
  • Vomiting
• Pet 2 Ear
  • Ear
• Please check all that apply.
  • Crusting or scabs in ear
  • Dark discharge from ear
  • Head shaking
  • Infection
  • Itchiness
  • Odor
  • Painful ear
  • Redness in the ear canal
  • Scratching at the affected ear
  • Swollen ear flap (HEMATOMA)
• Pet 2 Eye
  • Eye
• Please check all that apply.
  • Dilated pupils
  • Excessive blinking
  • Excessive tearing
  • Eye bulging
  • Eye cloudiness
  • Eye inflammation
  • Eye irritation
  • Eye pain
  • Eye redness
  • Gooey eye discharge
  • Inflammation around eye
  • Lump on eyelid
  • Pawing at the eyes
  • Squinting
• Pet 2 Prescription
  • Prescription Refill
• Tell us what you need
• Pet 2 Skin
  • Skin Disease
• Please check all that apply.
  • Allergy
  • Allergic dermatitis
  • Bumps / Lumps
  • Hair loss
  • Hot spots
  • Infection
  • Itching
  • Masses / tumors
  • Skin, painful to the touch
• Pet 2 Weight Change
  • Weight Change
• Change in weight?
• Pet 2 Vaccinations
  • Vaccinations
• Check applicable age. (pet 2)
  • Adult Dog (1-yr or older)
  • Puppy (select age range below)
  • Adult Cat (1-yr or older)
  • Kitten (select age range below)
• Puppy Age (weeks)*
  How old is your puppy? (weeks)
• Kitten Age (weeks)*
  How old is your kitten? (weeks)
• Pet 2 Heartworm Test
  • Heartworm Test
• Pet 2 Heartworm Preventative
  • Heartworm Preventative
• Pet 2 Flea Tick
  • Flea / Tick Preventative
• Pet 2 Other
  • Other, Not Listed
• Other important issues to discuss today:
• This may sound crazy, but did you bring a 3rd pet?
  • Yes
  • No

• Pet #3

• Pet 3 Name*
• Species (pet 3)*
  DogCat
• Breed*
• Color*
• Age*
• Gender / Fixed*
  MaleFemaleNeutered MaleSpayed Female
• Current diet, amount fed, & frequency*
• Last Veterinary Visit*
  MM slash DD slash YYYY
• Rabies Vaccine Current?*
  • YES
  • NO
  • NOT SURE
• Pet have known allergies? Please list, or state "N/A".*
• Eating normally?*
  • YES
  • NO
  • NOT SURE
• Drinking normally?*
  • YES
  • NO
  • NOT SURE
• Coughing?*
  • YES
  • NO
  • NOT SURE
• Sneezing?*
  • YES
  • NO
  • NOT SURE
• Currently on Heartworm Preventative? (pet 3)*
  • YES
  • NO
  • NOT SURE
• If "YES" to Heartworm, which brand?
• Currently on Flea / Tick Preventative? (pet 3)*
  • YES
  • NO
  • NOT SURE
• If "YES" to Flea / Tick, which brand?
• Current meds or supplements pet is taking:
  If "none", please indicate so.

• Why Am I Here Today? (Pet 3)

• Pet 3 Arthritis
  • Arthritis (or showing signs of arthritis)
• Please check all that apply.
  • Lagging behind on walks
  • Licking of the affected joint(s)
  • Limping / lameness
  • Pain or stiffness when getting up or down
  • Personality change (aggression when normally good-natured)
  • Reluctance to walk, climb stairs, jump or play.
  • Yelping when touched
• Pet 3 Bladder
  • Bladder / Urinary Tract
• Please check all that apply.
  • Bloody urination
  • Crying out or whining while urinating
  • Inappropriate urination (accidents in the house)
  • Increased frequency of urination
  • Licking genitals
  • Offensive (strong) odor in urine
  • painful urination
  • Straining to urinate
  • Urgency of urination
  • Urine dribbling
• Pet 3 Dental
  • Dental Disease
• Please check all that apply.
  • Bad breath
  • Bleeding or red gums
  • Blood in water bowl or on chew toys
  • Bloody saliva
  • Bumps or lumps in the mouth
  • Drooling
  • Loose teeth
  • Painful
  • Problem picking up food
  • Refusing to eat
  • Yellow-brown tarter on teeth
• Pet 3 Digestive
  • Digestive Problems
• Please check all that apply.
  • Blood or mucus in the stool
  • Constipation
  • Diarrhea
  • Excess gas or flatulance
  • Loss of appetite
  • Painful stomach area
  • Straining when passing stools
  • Vomiting
• Pet 3 Ear
  • Ear
• Please check all that apply.
  • Crusting or scabs in ear
  • Dark discharge from ear
  • Head shaking
  • Infection
  • Itchiness
  • Odor
  • Painful ear
  • Redness in the ear canal
  • Scratching at the affected ear
  • Swollen ear flap (HEMATOMA)
• Pet 3 Eye
  • Eye
• Please check all that apply.
  • Dilated pupils
  • Excessive blinking
  • Excessive tearing
  • Eye bulging
  • Eye cloudiness
  • Eye inflammation
  • Eye irritation
  • Eye pain
  • Eye redness
  • Gooey eye discharge
  • Inflammation around eye
  • Lump on eyelid
  • Pawing at the eyes
  • Squinting
• Tell us what you need
• Pet 3 Prescription
  • Prescription Refill
• Pet 3 Skin
  • Skin Disease
• Please check all that apply.
  • Allergy
  • Allergic dermatitis
  • Bumps / Lumps
  • Hair loss
  • Hot spots
  • Infection
  • Itching
  • Masses / tumors
  • Skin, painful to the touch
• Pet 3 Weight Change
  • Weight Change
• Change in weight?
• Pet 3 Vaccinations
  • Vaccinations
• Check applicable age. (pet 3)
  • Adult Dog (1-yr or older)
  • Puppy (select age range below)
  • Adult Cat (1-yr or older)
  • Kitten (select age range below)
• Puppy Age (weeks)*
  How old is your puppy? (weeks)
• Kitten Age (weeks)*
  How old is your kitten? (weeks)
• Pet 3 Heartworm Test
  • Heartworm Test
• Pet 3 Heartworm Preventative
  • Heartworm Preventative
• Pet 3 Flea Tick
  • Flea / Tick Preventative
• Pet 3 Other
  • Other, Not Listed
• Other important issues to discuss today:
• Bruh... you do NOT have a 4th pet... right?
  • Yes
  • No
• You qualify for a nickname.
• You qualify for a nickname.

• Referral

• Would you like a $20 credit added to your account?
  Thank you for being a great client. We've enjoyed serving you. If you're happy with the service you've received from our dedicated doctors and staff, would you like to refer someone? When they come in, you'll get a $20 credit to your account and they'll receive $20 off their first visit.
  • Yes
  • No
• Referral Name
  Who would you like to refer and save them $20 on their next visit, while earning yourself $20 credit?
  First Last
• Referral Email
  What is their email address?

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