Name: Veterinarian
Brand: Briar Patch Veterinary Hospital

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Other Medical History

If your pet has medical history from another veterinary facility, please have them email us the records to [email protected]

Pet's First Name

Pet's Last Name

Your First Name

Your Last Name

Your Email

It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed below available and be free to talk. If you need to leave your car, leave the parking lot, or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

What phone number can we use to reach you while your pet is with us?

Reason for your pet's visit today?

This issue began on

This issue is:

Has your pet had any:

Coughing

Sneezing

Vomiting

Diarrhea

New lumps or bumps

Behavior changes

Changes in mobility

Changes in bathroom habits

Other

Please describe

My pet's appetite is:

My pet's thirst level is:

My pet's activity level is:

My pet's urination is:

My pet eats

Wet food only

Dry food only

Wet and dry mixture

People food

Raw diet

Home cooked diet

Other

Brand(s) of Pet Food (please list all)

If prescription diet, what formulation?

How often is your pet fed?

How much is your pet fed PER MEAL?

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)

Has your pet's diet changed in the last 6 months?

Yes

I am not sure

Is it possible for your pet to have

Eaten garbage

Ingested mushrooms

Eaten toys (part of toys missing, chewed up etc.)

Ingested toxins (rat bait, ant bait, other known toxic substances)

Ingested marijuana

Ingested human or animal medications not intended for them or at higher doses than intended?

NONE OF THE ABOVE ARE POSSIBLE

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:

When was your pet's last dose of heartworm prevention?

(Date Given)

What brand of heartworm prevention do you use?

(Name of medication - put unknown if not sure)

When was your pet's last dose of flea and tick prevention?

(Date Given)

What brand of flea and tick prevention do you use?

(Name of medication - put unknown if not sure)

Do you need any medication or preventative refills or written prescriptions provided during your visit?

(Name of medications)

Is Your Pet

Indoor Only

Mostly Indoor but Rarely to Occasionally Spends Time Outdoors

Indoor/Outdoor

Outdoor Only

Outdoor During Day/Inside At Night

Other

What other pets are in your home?

Does Your Pet

Visit the dog park

Compete in Dog/Cat Shows

Attend Agility/Dock Diving/Search and Rescue programs etc.

Attend Doggie Daycare

Travel to lakes with you

Get Groomed Regularly

Attend Obedience Training

Board

Travel with you (outside state of the area)

Is Your Pet Current On Vaccinations?

Yes

I am not sure

My pet's vaccines were administered last by:

Briar Patch Veterinary Hospital

I Am Not Sure Where

Other

Does your pet have a microchip?

Yes

I am not sure

Does your pet have known health concerns and/or chronic disease or conditions?

Is there anything else we should know about your pet?

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

One file only.
1 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Is there anything else you would like to discuss today?

Appointment Procedures

I understand that Briar Patch Veterinary Hospital is operating under a fluid modified curbside protocol and access to the building might be limited. I will be appraised of the current protocol on my arrival or I will call ahead to ask about current policy.

Initial

I understand that I must remain at Briar Patch while my pet is undergoing evaluation and treatment unless a formal admission process has been completed. If I leave my pet with Briar Patch staff, I acknowledge that I will be charged an additional hospitalization fee of $47.

Initial

I understand that payment is due in full at the time services are rendered. This includes services authorized by another responsible party listed on my account; and/or by phone.

Initial

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