Client's Name *

First

Last

Email *

Patient's Name *

Patient's Species *

Canine
Feline
Other

If 'Other', please specify: *

Is this the first time we have seen your pet? *

Yes
No

What Veterinarian / Veterinary hospital previously cared for your pet? *

May we contact them for medical records? *

Yes
No

If No, please upload medical records

File Upload

Click or drag a file to this area to upload.

How long have you had your pet and from where did you obtain your pet? *

Does your pet have any previous medical history we should be aware of (Allergies/ surgeries/ chronic medical conditions) *

Yes
No

If yes, please explain *

Has your pet been vaccinated for rabies? *

Yes
No

Date of Vaccination *

Is your pet up to date on other vaccines? *

Yes
No

Please list.

Who will be bringing your pet in for the appointment? *

First

Last

What car will this person be in? *

(Please list the model and color.)

Best phone number for today's appointment: *

(The veterinarian and technician will use this number to communicate with you through the appointment.)

I consent to receive SMS text messages from Bristol County Veterinary Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

May we communicate via text during the appointment? *

Yes
No

What brings your pet in today? What is the primary reason for today’s visit? *

Is there anything else you would like to discuss with the doctor? *

Please complete the following questions about your pet:

Does your pet have pet insurance? *

Yes
No

If yes – Provider? *

Does your pet go outside? *

Yes
No

If yes, please describe your pets’ outdoor activities.

Does your pet participate in: (check all that apply)

If other, please explain *

Has anything changed in or with your household? Example People/Pets come or gone, construction, moving, etc. *

Yes
No

If yes, please explain

Does your pet take any medications? *

Yes
No

If so, please list including dosage.

Does your pet take any supplements? *

Yes
No

If so, please list including dosage.

Does your pet need any refills on Medications/ Supplements / Prescription Diets? *

Yes
No

If so, please specify.

Is your pet on Heartworm Prevention? *

If Other, please specify.

Does your pet receive heartworm prevention year-round? *

Yes
No

Is your pet on Flea and Tick Prevention? *

If Other, please specify.

Does your pet receive flea and tick prevention year-round? *

Yes
No

Please describe your pets diet including the type and amount of food they eat, including any treats or human food. *

Has your pet or is your pet currently experiencing any of the following? (please check all that apply and describe) *

Does your pet need any additional services today? *

Nail trim
Ear cleaning
Anal gland expression
Sanitary clip

Is there anything else you would like to share with us about your pet? *

Signature

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