Information about the pet we will be seeing:

Name *

Species *

Canine
Feline

Breed *

Color *

Date of Birth/Age *

Gender *

Female
Male

Spayed or neutered *

Yes
No

Who was your pet’s previous veterinary clinic?

No prior veterinary clinics (new pet, puppy, etc)
Please list prior clinic(s):

Please list prior clinic(s):

When was the last time your pet was seen by a veterinarian?

Approximate date/year
No prior veterinary visits

Approximate date/year *

Information about you:

Name *

Spouse/Other

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone Number *

Secondary Phone Number

Spouse Phone Number

Other Phone Numbers

Email Address *

Would you prefer to be contacted by text, email or phone call?

Text
Email
Phone call

I would like to receive my pet's reminders by email *

Yes
No

Who should we contact to make medical decisions at your pet's appointment? *

Owner (Named Above)
Someone Else (Named Below)

Full name of other person to contact for medical decisions *

First

Last

At what number can they be reached today? *

Reason for visit: (check all that apply) *

Illness
Injury
Other

If other, please explain *

What symptoms has your pet been experiencing?

Are there any concerns for the following: (check all that apply)

Skin Masses (explain below) *

If other, please explain *

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them?

No change
Worsened
Improved

Has your pet experienced this problem in the past?

Yes
No

Has your pet had any exposure to toxins (cleaners, chemicals, etc.) or drugs/medications (prescription, OTC, recreational)?

Yes
No

If yes, give details below. *

Any Known Allergies/Reactions? *

Yes
No

If yes, please explain *

Does your pet have any pre-existing medical conditions we should be aware of (e.g., seizures, heart disease, kidney disease, etc.) *

Yes
No

If yes, give details below. *

Is your pet on any medications?

Yes
No

If yes, give details below. *

Other procedures: (All procedures at additional cost)

Anal glands
Ear cleaning

What brand and type of food do you feed your pet? *

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often)

Measured amount (specify how much and how often) *

Do you do any dental care at home (tooth brushing, dental chews, etc.)? If yes, give details below.

Do you have insurance for your pet? *

Yes
No

If yes, what insurance? *

Do you give your pet heartworm or flea/tick preventative? *

Yes (specify product(s) and last time given)
No

If yes, specify product(s) and last time given *

Have you seen any fleas or ticks on your pet?

Yes (specify - fleas or ticks?)
No

If yes, fleas or ticks? *

Do you wish to take home flea/tick/heartworm prevention today? *

Yes
No
Unsure, speak with a veterinarian about recommendations for my pet

What percentage of time does your pet spend outside?

Do you have other pets? *

Yes
No

Does your pet come into contact with other dogs? Please check all that apply *

If other, please specify *

Many of our patients love peanut butter as a snack while visiting our office, but if you or your pet have an allergy to peanut butter, please let us know.

Can your pet have peanut butter? *

Yes
No

Credit Policy: We ask that all fees be paid at the time of service. *

I have read and understand.

Please see our Payment Options

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand.

I give Russell Lake Animal Hospital authorization to treat as discussed above. *

I have read and understand.

*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment. *

I have read and understand.

Please arrive a few minutes early or on time to check in. Late arrivals may not be accommodated and a late fee of $50 may be applied to your account. Once the exam has been performed and a plan has been discussed we will obtain your consent and proceed with providing treatment. *

I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Yes
No

Whom may we thank for referring you to us? (check one)

If they are clients at our hospital, whom may we thank? *

Staff Member *

If other, please explain *

Please type your initials. *

Date *

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