Please select your clinic: *

Owner's Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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

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? *

What brand of food are you feeding your pet, and how much/how often are you feeding your pet? *

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 spend any amount of time with access to standing water (ponds, creeks, lakes, puddles, etc.) 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 ($24)
No

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

Yes
No

We recommend a Bordetella and K9 Flu vaccine, would you like us to provide these vaccines today? *

Bordetella ($24)
K9 Flu ($29)
None

Has your cat had a FIV/FeLV combo test? *

Yes
No

When was the test performed and what were the results? *

Would you like a nail trim ($20)? *

Yes
No

Would you like an ear cleaning ($28)? *

Yes
No

Would you like to have your pet microchipped? ($61) *

Yes
No

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

Yes ($29)
No

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