Patient Exam Questionnaire

Please fill out this exam summary electronically prior to your appointment.

Client/Owner Full Name *

First

Last

Are you a "New" or "Existing" client? *

New
Existing

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Partner Name if applicable

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Can we text this number? *

Secondary Phone

Can we text this number?

Email *

Your pet's medical/vaccination records may be requested by another provider for services including routine or urgent care, medical specialists, boarding, grooming and adoption services. *

I hereby authorize and provide for the transfer of my pet's medical records as deemed necessary by Family Pet Health.
I do NOT authorize or provide for the transfer of my pet's medical records.

Your pet's picture or video may be taken while they are with us and used for Family Pet Health’s advertisement (https://familypethealth.com/) or other social media purposes (Facebook, SnapChat, Instagram, etc). Please indicate if you authorize for their pictures/videos to be posted or used. *

I approve for Family Pet Health to post and use all pictures/videos taken of my pet.
I do NOT authorize Family Pet Health to post or use any pictures/videos taken of my pet.

If you do not authorize for your pet’s picture to be included in our marketing materials/venues we may still use a picture of your pet in our patient records for our internal identification only.

What is your pet's social media account if you have one?

How did you hear about us? *

Personal Referral
Social Media
Sign/Drove By
New Resident Program
Google Search
Other

Whom shall we thank? *

If Other, please describe *

Which one? *

Facebook
Instagram
YouTube
Twitter
Other

If Other, please explain *

Has any of your personal information (phone number, email address) changed since your last visit? *

Phone *

Email *

Your pet's medical/vaccination records may be requested by another provider for services including routine or urgent care, medical specialists, boarding, grooming and adoption services. *

I hereby authorize and provide for the transfer of my pet's medical records as deemed necessary by Family Pet Health.
I do NOT authorize or provide for the transfer of my pet's medical records.

I approve for Family Pet Health to post and use all pictures/videos taken of my pet.
I do NOT authorize Family Pet Health to post or use any pictures/videos taken of my pet.

If you do not authorize for your pet’s picture to be included in our marketing materials/venues we may still use a picture of your pet in our patient records for our internal identification only.

Patient's Name *

Appointment Date & Time

Date

Time

Patient's Species *

Canine
Feline
Other

If Other, please describe *

Patient's Sex *

Male
Neutered Male
Female
Spayed Female

Patient Age *

Puppy (0-12 months)
Adult (1-7 years)
Senior (7+ years)

Patient Age *

Kitten (0-12 months)
Adult (1-11 years)
Senior (11+ years)

How old is your cat? *

How old is your dog? *

What is your kitten's birthday? *

What is your puppy's birthday?

Is the upcoming visit a wellness exam or an exam for a sick pet? *

Wellness Exam
Exam for a sick pet

Do you have pet insurance? *

Yes
No
No, but I am interested in learning about pet insurance

Name of Insurance Provider *

Primary Reason for Appointment/Concerns

Please be as detailed as possible

How long has the medical condition existed?

Has your pet seen another veterinarian? *

Name of Clinic *

Patient's Energy Level

Normal
Increased
Decreased

Patient's Appetite

Normal
Increased
Decreased

Water Intake/Drinking

Normal
Increased
Decreased

Is the patient coughing?