This form is for scheduled appointments only. New to our hospital? Please head over to our New Client Registration Form! Client InformationFirst Name *Last Name *Phone *Best number to reach you at on the day of your appointmentWill the primary owner on the account be present for the appointment? *YesNoIf no, please provide the name of the individual that will be at the appointment: *Is this individual over 18 years old? *YesNo - Please reschedule appointmentDo they have permission to make medical decisions for your pet? *YesNo - Please reschedule appointmentPatient InformationPet's Name *Reason for your pet's visit?This issue began on:(leave blank if no issues or concerns)This issue is...ImprovingContinuing (stable or unchanging)WorseningIs your pet current on vaccinations? *YesNoI am not sureMy pet's vaccines were administered last by: *Evanston Animal HospitalI am not sure whereOther (previous veterinarian, vaccine clinic, shelter, etc)Where were vaccines last administered? Please include contact information. *Does your pet have a microchip?YesNoI am not sure - Please scan them at the visit!Has your pet bitten anyone in the last 15 days? *YesNoI am not surePatient Health QuestionsHas your pet had any coughing, sneezing, vomiting, diarrhea?CoughingSneezingVomitingDiarrheaNone of the aboveIf yes, please describeHas your pet had any:New lumps or bumpsBehavior changesChanges in mobilityNone of the aboveIf yes, please describeMy pet's appetite is:NormalIncreasedDecreasedIf increased or decreased, please provide more information:My pet's thirst level is:NormalIncreasedDecreasedIf increased or decreased, please provide more information:My pet's activity level is:NormalIncreasedDecreasedIf increased or decreased, please provide more information:My pet's urination is:NormalAbnormalIf abnormal, please provide more information:Diet & MedicationsMy pet eats:Wet food onlyDry food onlyWet and dry mixturePeople foodRaw dietHome cooked dietHas your pet's diet changed in the last 6 months?YesNoI am not sureBrand of food:If prescription diet, what formulation?How often and how much is your pet fed?In addition to pet food, what treats or other food does your pet receive?Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:What Kind of Heartworm Preventative Do You Use?When Was Your Pet's Last Dose of Heartworm Preventative?What Kind of Flea/Tick Preventative Do You Use?When Was Your Pet's Last Dose of Flea/Tick Preventative?Do you need any medication or preventative refills? If so, please list below.LifestyleIs your pet:Indoor onlyMostly Indoor but rarely to occasionally spends time outdoorsIndoor/outdoorOutdoor onlyOutdoor during day/inside at nightOtherAre there other pets in the home?YesNoPlease tell us about the other pet(s) in your homeDoes your pet currently or plan to:Visit the dog parkGet groomed regularlyAttend obedience trainingAttend doggie daycare or boarding facilityTravel with you domesticallyTravel with you internationallyFinal QuestionsIs there anything else we should know about your pet, or would like to discuss at your appointment?Need to submit patient records? Upload file(s) belowDrag and Drop (or) Choose FilesConsent to Evanston Animal Hospital's Protocols *Yes, I understand the hospital protocols, including payment policies and late fees.Wearing a mask?Our hospital is "mask optional". Please let us know if you prefer that our team members are masked while in the exam room. Masks are available upon request if you forget to bring one.Submit FormPlease do not fill in this field.
