16731 McGregor Blvd. Ste 115 Fort Myers, FL 33908 | dociris@affectionatelypets.com
 
 
 
 
 
 
 

Pet Wellness Center New Patient Intake Form

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Owner’s Information
 
 
Name:
 
 
 
 
Significant Other:
 
 
 
 
 
Address:
 
 
 
Circle One
 
APT/Unit/Lot #:
 
 
 
 
 
City:
 
 
 
 
 
State:
 
 
 
 
Zip:
 
 
 
 
 
 
Home Phone:
 
 
 
 
Cell Phone:
 
 
 
 
 
Other Phone:
 
 
 
 
Explain:
 
 
 
 
 
Email Address:
 
 
 
Print in all capitals
 
Best Way to Contact you?
 
 
 
 
 
 
Pet Information
 
 
Pets Name:
 
 
 
 
DOB:
 
 
 
 
Age:
 
 
 
 
 
Breed:
 
 
 
 
Color:
 
 
 
 
 
Species:
 
 
 
 
Sex:
 
 
 
 
Spayed/Neutered Microchip?
 
 
 
 
Purpose
 
 
 
Behavioral Assessment
 
What is your pet’s disposition? I.e. alert, shy, anxious timid, depressed, dominant, aggressive (people or animals) etc. Please explain;
 
Describe your pet in 3 words
 
Any General Sensitivity? Heat, cold, outside
 
Diet and Nutrition
 
Food Brand Name:
 
 
 
 
How much?
 
 
 
 
How often?
 
 
 
 
 
Flea/ Tick prevention? YES or NO If yes, What brand?
 
 
 
 
Date of last dose:
 
 
 
 
 
Heartworm Prevention? YES or NO If yes, What brand?
 
 
 
 
Date of last dose:
 
 
 
Supplements: Please include the brand, product how much, how often you give it to your pet
 
Chief Complaint
 
What is the main reason for your visit today?
 
When did it start? Anything make it better?
 
What is your goal for today’s appointment?
 
Seen by another vet for this issue? Yes or No
 
 
Clinic name:
 
 
 
 
Phone Number:
 
 
 
Medical History
 
Inherited conditions – (hip dysplasia, cancer, diabetes, congenital heart defects)
 
Known allergies?
 
Date of last Dental Cleaning?
 
Any Surgeries? If so, when?