Scheduled Appointment Form

Personal Information

Name(Required)

First Last

Phone(Required)

Are you new to Guardian Veterinary Medical Center?(Required)

Yes

Patient Name(Required)

Species(Required)

Gender(Required)

Age/DOB if known

Breed(Required)

Color(Required)

Does your pet do better with male or female employees?(Required)

***Please specify doctor and technician***

Please Specify Which Staff Member You Would Like To See

Are there any areas your pet does not like touched?(Required)

If Yes, Please Specify

Reason for visit and presenting concerns (if any)(Required)

How long has your pet been experiencing these symptoms?(Required)

Have you tried any home treatments?(Required)

If Yes, Please Explain

DIET AND MEDICATIONS

Any change in diet or access to foods other than recommended pet food? Any consumption of foreign materials?(Required)

If Yes, Please Explain

Current diet and amount(Required)

(including treats/people food)

Current medications and flea/tick/heartworm preventions (including over the counter and supplements)(Required)

***Please provide dosage and frequency***

PATIENT BEHAVIOR

Appetite(Required)

Water Intake(Required)

Urinary Habits(Required)

Lethargy?(Required)

Sneezing?(Required)

Coughing?(Required)

Vomiting?(Required)

Diarrhea?(Required)

Please provide the duration along with a brief description of any behavioral changes mentioned above (i.e contents of vomit, color of diarrhea, etc.)(Required)

PRE-EXISTING CONDITIONS AND PRIOR RECORDS

Any allergies or prior reactions?(Required)

If Yes, Please Explain

Any allergies or prior reactions?(Required)

If Yes, Please Explain

Please provide the clinic name and contact information to obtain any prior medical records (including any specialty or emergency clinics)

Name

Phone

Name

Phone

CONSENT FOR TREATMENT

I authorize Guardian Veterinary Medical Center to give treatment to the above named animal. I authorize them to obtain all prior medical records regarding my pet. I assume full financial responsibility and understand that professional fees are due at the time services are rendered. By signing below, I certify that I have read and understand the above information and that all information listed above is true.

Signature(Required)

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