Please select your clinic: *

Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

Approximate Weight *

Reason for Visit *

Where does your pet live? *

Indoor Only
Indoor/Outdoor (for elimination only)
Indoor/Outdoor
Outdoor Only

If yes, for how long? *

Is your pet eating/drinking well? *

Yes
No

If not, please explain and include when this began. *

Has your pet been coughing or sneezing? *

No
Yes, coughing
Yes, sneezing

If yes, please explain and include when it began. *

Has your pet had any diarrhea or vomiting? *

No
Yes, vomiting
Yes, diarrhea (if so, please bring a sample)

If so, when did this start and how many times has it occurred? *

Is your pet urinating normally? *

Yes
No

What urination issues is your pet having and how long has this been occurring? *

Pet's Current Diet *

Brand of food *

Frequency fed *

Amount given *

Pet's Medical History (surgeries, medical conditions, etc.) *

Is your pet on heartworm prevention? *

Yes
No

Brand *

Last Dose *

Do you need a refill? *

Yes
No

Is your pet on flea/tick prevention? *

Yes
No

Brand *

Last Dose *

Do you need a refill? *

Yes
No

Does your pet have history of vaccine reactions? *

Yes
No

If yes, please explain *

Is your pet currently on any medications/supplements? *

Yes
No

If yes, please explain *

Does your pet have any previous medical issues? *

Yes
No

If yes, please explain *

Does your pet have access to lakes, ponds, creeks, standing water, or wildlife? *

Yes
No

In 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? *

Yes
No

Does your pet go to grooming, boarding, dog parks, or day care? *

Yes
No

Is your pet indoor, outdoor, or both? *

Indoor
Outdoor
Both

Has your cat received the FIV/FELV vaccine? *

Yes
No

Would you like a nail trim ($18)? *

Yes
No

Would you like an ear cleaning ($25)? *

Yes
No

Would you like to have your pet microchipped? ($46.50) *

Yes
No

If your pet is a feline and spends any amount of time outdoors, we recommend a FeLV vaccine, would you like us to provide this vaccine? *

Yes ($26)
No

If your pet is a canine and spends any amount of time with access to standing water (ponds, creeks, puddles, etc.), we recommend a Lepto vaccine, would you like us to provide this vaccine? *

Yes ($22)
No

If your pet is a canine and spends any amount of time with other dogs (grooming, boarding, daycare, dog parks, etc.), we recommend a Bordetella and K9 Flu vaccine, would you like us to provide these vaccines? (check all that apply) *

Bordetella ($22)
K9 Flu ($35)
Both ($57)
None

Any additional services?

Signature *

Date *

Express Vets
Patient Check-In Form

Use the form below to submit your patient check-in form.

We look forward to seeing you and your pet!

Author

Express Vets Patient Check-In Form

Use the form below to submit your patient check-in form.

We look forward to seeing you and your pet!

Author

Express Vets
Patient Check-In Form