Express Vets Patient Check-In Form Primary Care For Pets™ Use the form below to submit your patient check-in form. We look forward to seeing you and your pet! Please enable JavaScript in your browser to complete this form.Please select your clinic: *CummingNorth CantonHolly SpringsKennesawBufordOwner's Name *FirstLastPhone *Email *Pet's Name *Species *DogCatSex *MaleMale (neutered)FemaleFemale (spayed)Age/Date of Birth *Approximate Weight *Reason for Visit *Is your pet eating/drinking well? *YesNoIf yes, for how long? *Has your pet been coughing or sneezing? *YesNoIf yes, for how long? *Has your pet had any diarrhea or vomiting? *YesNoIf so, when did this start and how many times has it occurred? *Pet's Current Diet *Pet's Medical History (surgeries, medical conditions, etc.) *Is your pet on heartworm prevention? *YesNoBrand *Last Dose *Do you need a refill? *YesNoIs your pet on flea/tick prevention? *YesNoBrand *Last Dose *Do you need a refill? *YesNoDoes your pet have history of vaccine reactions? *YesNoIf yes, please explain *Is your pet currently on any medications/supplements? *YesNoIf yes, please explain *Does your pet have any previous medical issues? *YesNoIf yes, please explain *Does your pet have access to lakes, ponds, creeks, standing water, or wildlife? *YesNoIn the state of Georgia, wildlife is prevalent, and we recommend having your dog vaccinated for Leptospirosis (a bacterial disease that affects humans and animals). Would you like for your pet to have this vaccine? *YesNoDoes your pet go to grooming, boarding, dog parks, or day care? *YesNoIs your pet indoor, outdoor, or both? *IndoorOutdoorBothHas your cat received the FIV/FELV vaccine? *YesNoWould you like a nail trim ($16)? *YesNoWould you like an ear cleaning ($23)? *YesNoAny additional services?Signature *Clear SignatureDate *Submit Author Erika Nielsen View all posts
