Pet Intake Form

1. Basic Pet Information

Client Full Name: *

Phone *

Email *

Pet's Name

Animal Type (Dog, Cat, Llama, etc.) *

• Male
• Female
• Spayed
• Neutered

Approx. Age at Spay/Neuter:

Approx. Age Now:

Birth Month/Year (if known):

• Had pet since birth
• Did not have since birth

If no, since when?

Circumstances of acquisition:

2. Vaccination History

List any and all vaccines you recall:

List any problems or reactions following vaccines:

3. Medication History

List any medications your pet has been given:

List any medication reactions you recall:

4. Health History

List any noted illnesses, traumas, or surgeries:

Explain details (dates, circumstances, outcomes):

Month/Year

5. Primary Concerns

1. Concern:

Visible symptoms:

2. Concern:

Visible symptoms:

3. Concern:

Visible symptoms:

6. Eating Habits

Type of food:

• Good Eater
• Picky Eater
• Other

Additional notes on appetite or digestion:

7. Social & Emotional Environment

Other people or animals in the pet’s lifetime:

Loss of other people or animals that may have impacted your pet:

Relationship issues in the home (if any):

Who is the pet closest to?

Who is the pet most distant from?

• Gets along with other pets
• Does not get along with other pets

If no, please explain (jealousy, anger, fear, aggression, sadness, or other):

8. Physical Condition

• Overweight
• Underweight
• Average weight

List any diagnoses or medical conditions:

Additional Notes

Submit