Pet Check-in Form

Use this form if you already have an appointment.
If you need to MAKE AN APPOINTMENT, click here.

APPOINTMENT CHECK IN

Please complete and submit this form BEFORE your appointment time, to ensure our staff is ready when your pet arrives.

Are you a current client? Have you been here before?*
- Yes
- No
Appointment Type?*
- Wait
- Scheduled Drop-Off
Date of Appointment*
What is the scheduled date of your appointment?

MM slash DD slash YYYY
What time is your appointment scheduled for?*

:
Hours

Minutes

AM/PM
Your Name*

First

Last
Address*

Street Address

Address Line 2

City

State

ZIP Code
Primary Email*
Mobile Phone*
Pet #1
Pet Name*
Species (pet 1)*
Breed*
Color*
Age*
Gender / Fixed*
Current diet, amount fed, & frequency*
Last Veterinary Visit*

MM slash DD slash YYYY
Rabies Vaccine Current?*
- YES
- NO
- NOT SURE
Pet have known allergies? Please list, or state "N/A".*
Eating normally?*
- YES
- NO
- NOT SURE
Drinking normally?*
- YES
- NO
- NOT SURE
Coughing?*
- YES
- NO
- NOT SURE
Sneezing?*
- YES
- NO
- NOT SURE
Currently on Heartworm Preventative?*
- YES
- NO
- NOT SURE
If "YES" to Heartworm, which brand?
Currently on Flea / Tick Preventative?*
- YES
- NO
- NOT SURE
If "YES" to Flea / Tick, which brand?
Current meds or supplements pet is taking:*
If “none”, please indicate so.
Why Am I Here Today?
Pet 1 Arthritis
- Arthritis (or showing signs of arthritis)
Please check all that apply.
- Lagging behind on walks
- Licking of the affected joint(s)
- Limping / lameness
- Pain or stiffness when getting up or down
- Personality change (aggression when normally good-natured)
- Reluctance to walk, climb stairs, jump or play.
- Yelping when touched
Pet 1 Bladder
- Bladder / Urinary Tract
Please check all that apply.
- Bloody urination
- Crying out or whining while urinating
- Inappropriate urination (accidents in the house)
- Increased frequency of urination
- Licking genitals
- Offensive (strong) odor in urine
- painful urination
- Straining to urinate
- Urgency of urination
- Urine dribbling
Pet 1 Dental Disease
- Dental Disease
Please check all that apply.
- Bad breath
- Bleeding or red gums
- Blood in water bowl or on chew toys
- Bloody saliva
- Bumps or lumps in the mouth
- Drooling
- Loose teeth
- Painful
- Problem picking up food
- Refusing to eat
- Yellow-brown tarter on teeth
Pet 1 Digestive Problems
- Digestive Problems
Please check all that apply.
- Blood or mucus in the stool
- Constipation
- Diarrhea
- Excess gas or flatulance
- Loss of appetite
- Painful stomach area
- Straining when passing stools
- Vomiting
Pet 1 Ear
- Ear
Please check all that apply.
- Crusting or scabs in ear
- Dark discharge from ear
- Head shaking
- Infection
- Itchiness
- Odor
- Painful ear
- Redness in the ear canal
- Scratching at the affected ear
- Swollen ear flap (HEMATOMA)
Pet 1 Eye
- Eye
Please check all that apply.
- Dilated pupils
- Excessive blinking
- Excessive tearing
- Eye bulging
- Eye cloudiness
- Eye inflammation
- Eye irritation
- Eye pain
- Eye redness
- Gooey eye discharge
- Inflammation around eye
- Lump on eyelid
- Pawing at the eyes
- Squinting
Pet 1 Prescription Refill
- Prescription Refill
Tell us what you need
Pet 1 Skin Disease
- Skin Disease
Please check all that apply.
- Allergy
- Allergic dermatitis
- Bumps / Lumps
- Hair loss
- Hot spots
- Infection
- Itching
- Masses / tumors
- Skin, painful to the touch
Pet 1 Weight Change
- Weight Change
Change in weight?
Pet 1 Vaccinations
- Vaccinations
Check applicable age. Pet 1
- Adult Dog (1-yr or older)
- Puppy (select age range below)
- Adult Cat (1-yr or older)
- Kitten (select age range below)
Puppy Age (weeks)*
How old is your puppy? (weeks)
Kitten Age (weeks)*
How old is your kitten? (weeks)
Pet 1 Heartworm Test
- Heartworm Test
Pet 1 Heartworm Preventative
- Heartworm Preventative
Pet 1 Flea Tick
- Flea / Tick Preventative
Pet 1 Other
- Other, Not Listed
Other important issues to discuss today:
Did you bring another pet?
- Yes
- No
Pet #2
Pet 2 Name*
Species (pet 2)*
Breed*
Color*
Age*
Gender / Fixed*
Current diet, amount fed, & frequency*
Last Veterinary Visit*

MM slash DD slash YYYY
Rabies Vaccine Current?*
- YES
- NO
- NOT SURE
Pet have known allergies? Please list, or state "N/A".*
Eating normally?*
- YES
- NO
- NOT SURE
Drinking normally?*
- YES
- NO
- NOT SURE
Coughing?*
- YES
- NO
- NOT SURE
Sneezing?*
- YES
- NO
- NOT SURE
Currently on Heartworm Preventative? (pet 2)*
- YES
- NO
- NOT SURE
If "YES" to Heartworm, which brand?
Currently on Flea / Tick Preventative? (pet 2)*
- YES
- NO
- NOT SURE
If "YES" to Flea / Tick, which brand?
Current meds or supplements pet is taking:
If “none”, please indicate so.
Why Am I Here Today? (Pet 2)
Pet 2 Arthritis
- Arthritis (or showing signs of arthritis)
Please check all that apply.
- Lagging behind on walks
- Licking of the affected joint(s)
- Limping / lameness
- Pain or stiffness when getting up or down
- Personality change (aggression when normally good-natured)
- Reluctance to walk, climb stairs, jump or play.
- Yelping when touched
Pet 2 Bladder
- Bladder / Urinary Tract
Please check all that apply.
- Bloody urination
- Crying out or whining while urinating
- Inappropriate urination (accidents in the house)
- Increased frequency of urination
- Licking genitals
- Offensive (strong) odor in urine
- painful urination
- Straining to urinate
- Urgency of urination
- Urine dribbling
Pet 2 Dental
- Dental Disease
Please check all that apply.
- Bad breath
- Bleeding or red gums
- Blood in water bowl or on chew toys
- Bloody saliva
- Bumps or lumps in the mouth
- Drooling
- Loose teeth
- Painful
- Problem picking up food
- Refusing to eat
- Yellow-brown tarter on teeth
Pet 2 Digestive
- Digestive Problems
Please check all that apply.
- Blood or mucus in the stool
- Constipation
- Diarrhea
- Excess gas or flatulance
- Loss of appetite
- Painful stomach area
- Straining when passing stools
- Vomiting
Pet 2 Ear
- Ear
Please check all that apply.
- Crusting or scabs in ear
- Dark discharge from ear
- Head shaking
- Infection
- Itchiness
- Odor
- Painful ear
- Redness in the ear canal
- Scratching at the affected ear
- Swollen ear flap (HEMATOMA)
Pet 2 Eye
- Eye
Please check all that apply.
- Dilated pupils
- Excessive blinking
- Excessive tearing
- Eye bulging
- Eye cloudiness
- Eye inflammation
- Eye irritation
- Eye pain
- Eye redness
- Gooey eye discharge
- Inflammation around eye
- Lump on eyelid
- Pawing at the eyes
- Squinting
Pet 2 Prescription
- Prescription Refill
Tell us what you need
Pet 2 Skin
- Skin Disease
Please check all that apply.
- Allergy
- Allergic dermatitis
- Bumps / Lumps
- Hair loss
- Hot spots
- Infection
- Itching
- Masses / tumors
- Skin, painful to the touch
Pet 2 Weight Change
- Weight Change
Change in weight?
Pet 2 Vaccinations
- Vaccinations
Check applicable age. (pet 2)
- Adult Dog (1-yr or older)
- Puppy (select age range below)
- Adult Cat (1-yr or older)
- Kitten (select age range below)
Puppy Age (weeks)*
How old is your puppy? (weeks)
Kitten Age (weeks)*
How old is your kitten? (weeks)
Pet 2 Heartworm Test
- Heartworm Test
Pet 2 Heartworm Preventative
- Heartworm Preventative
Pet 2 Flea Tick
- Flea / Tick Preventative
Pet 2 Other
- Other, Not Listed
Other important issues to discuss today:
This may sound crazy, but did you bring a 3rd pet?
- Yes
- No
Pet #3
Pet 3 Name*
Species (pet 3)*
Breed*
Color*
Age*
Gender / Fixed*
Current diet, amount fed, & frequency*
Last Veterinary Visit*

MM slash DD slash YYYY
Rabies Vaccine Current?*
- YES
- NO
- NOT SURE
Pet have known allergies? Please list, or state "N/A".*
Eating normally?*
- YES
- NO
- NOT SURE
Drinking normally?*
- YES
- NO
- NOT SURE
Coughing?*
- YES
- NO
- NOT SURE
Sneezing?*
- YES
- NO
- NOT SURE
Currently on Heartworm Preventative? (pet 3)*
- YES
- NO
- NOT SURE
If "YES" to Heartworm, which brand?
Currently on Flea / Tick Preventative? (pet 3)*
- YES
- NO
- NOT SURE
If "YES" to Flea / Tick, which brand?
Current meds or supplements pet is taking:
If “none”, please indicate so.
Why Am I Here Today? (Pet 3)
Pet 3 Arthritis
- Arthritis (or showing signs of arthritis)
Please check all that apply.
- Lagging behind on walks
- Licking of the affected joint(s)
- Limping / lameness
- Pain or stiffness when getting up or down
- Personality change (aggression when normally good-natured)
- Reluctance to walk, climb stairs, jump or play.
- Yelping when touched
Pet 3 Bladder
- Bladder / Urinary Tract
Please check all that apply.
- Bloody urination
- Crying out or whining while urinating
- Inappropriate urination (accidents in the house)
- Increased frequency of urination
- Licking genitals
- Offensive (strong) odor in urine
- painful urination
- Straining to urinate
- Urgency of urination
- Urine dribbling
Pet 3 Dental
- Dental Disease
Please check all that apply.
- Bad breath
- Bleeding or red gums
- Blood in water bowl or on chew toys
- Bloody saliva
- Bumps or lumps in the mouth
- Drooling
- Loose teeth
- Painful
- Problem picking up food
- Refusing to eat
- Yellow-brown tarter on teeth
Pet 3 Digestive
- Digestive Problems
Please check all that apply.
- Blood or mucus in the stool
- Constipation
- Diarrhea
- Excess gas or flatulance
- Loss of appetite
- Painful stomach area
- Straining when passing stools
- Vomiting
Pet 3 Ear
- Ear
Please check all that apply.
- Crusting or scabs in ear
- Dark discharge from ear
- Head shaking
- Infection
- Itchiness
- Odor
- Painful ear
- Redness in the ear canal
- Scratching at the affected ear
- Swollen ear flap (HEMATOMA)
Pet 3 Eye
- Eye
Please check all that apply.
- Dilated pupils
- Excessive blinking
- Excessive tearing
- Eye bulging
- Eye cloudiness
- Eye inflammation
- Eye irritation
- Eye pain
- Eye redness
- Gooey eye discharge
- Inflammation around eye
- Lump on eyelid
- Pawing at the eyes
- Squinting
Tell us what you need
Pet 3 Prescription
- Prescription Refill
Pet 3 Skin
- Skin Disease
Please check all that apply.
- Allergy
- Allergic dermatitis
- Bumps / Lumps
- Hair loss
- Hot spots
- Infection
- Itching
- Masses / tumors
- Skin, painful to the touch
Pet 3 Weight Change
- Weight Change
Change in weight?
Pet 3 Vaccinations
- Vaccinations
Check applicable age. (pet 3)
- Adult Dog (1-yr or older)
- Puppy (select age range below)
- Adult Cat (1-yr or older)
- Kitten (select age range below)
Puppy Age (weeks)*
How old is your puppy? (weeks)
Kitten Age (weeks)*
How old is your kitten? (weeks)
Pet 3 Heartworm Test
- Heartworm Test
Pet 3 Heartworm Preventative
- Heartworm Preventative
Pet 3 Flea Tick
- Flea / Tick Preventative
Pet 3 Other
- Other, Not Listed
Other important issues to discuss today:
Bruh… you do NOT have a 4th pet… right?
- Yes
- No
You qualify for a nickname.
You qualify for a nickname.
Referral
Would you like a $20 credit added to your account?
Thank you for being a great client. We’ve enjoyed serving you. If you’re happy with the service you’ve received from our dedicated doctors and staff, would you like to refer someone? When they come in, you’ll get a $20 credit to your account and they’ll receive $20 off their first visit.
- Yes
- No
Referral Name
Who would you like to refer and save them $20 on their next visit, while earning yourself $20 credit?

First

Last
Referral Email
What is their email address?

APPOINTMENT CHECK IN

Pet #1

Why Am I Here Today?

Pet #2

Why Am I Here Today? (Pet 2)

Pet #3

Why Am I Here Today? (Pet 3)

Referral