Patient History Form

Pet's Name*

Name of Owner*

Owner's Date of Birth*

Email*

Mailing Address*

Primary Phone*

Secondary Phone

Tertiary Phone

What brand of food do you feed your pet?*

Is it grain free?*

Yes
No
Don't Know

Dry, canned or both?*

How much? How often?*

Is your pet on monthly flea/tick prevention?*

Yes
No

If YES, what date was the last dose applied or given to your pet?

If YES, where do you purchase your flea/tick prevention?

Is your pet on monthly heartworm prevention (canines only)?*

Yes
No

If YES, what date was the last dose given to your pet?

If YES, where do you purchase the heartworm prevention?

Medications, Vitamins, Supplements*

Please list all medications, including vitamins, herbal or natural supplements, prescription and over the counter medications your pet is currently taking. Please note the dosage.

Does your pet currently have diarrhea?*

Yes
No

Is your pet vomiting, coughing or sneezing?*

Yes
No

If YES, please explain:

Is your pet eating and drinking normal amounts?*

Yes
No

If NO, please explain:

Are you providing in home dental care?

Yes
No

If YES, please describe your routine:

ALLERGIES?*

Our goal is to provide a fun, fear free visit for your pets. One of the tools we use to do that is lots of food rewards of various kinds. Do you or anyone in your family (including your pets) have any food allergies that we should be aware of? If the answer is "yes" please list them in your reply.

Photo/Video Consent*

We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials, advertising and signage for the hospital. We will never do this without your consent. Please select all that apply:

Photos/videos of my pet(s) only
Photos/videos of me with my pet(s)
I DO NOT grant photo/video permission

Photo/Video Sharing*

When granting permission to take and share photos/videos of my pet(s), I hereby release Sayrebrook Veterinary Hospital from any and all claims arising from the use of the photos/videos. Sayrebrook Veterinary Hospital has my permission to use:

Only my pet's name(s)
My pet's name(s) and my last name
My pet's name(s) and my first and last name
I DO NOT grant photo/video permission

Do you have any specific questions or concerns you would like the veterinarian to address today?

Name of person completing form and relationship to owner:*

Our financial policy: Payment in full is due when services are rendered. We accept Cash, Debit Cards, Care Credit, Wells Fargo Health Advantage and major Credit Cards. Personal checks are not accepted. A minimum of 30% is required as a deposit for all major surgeries and/or hospitalizations at the time of admittance. Emergency cases require a minimum of 50% of the estimated treatment plan at time of admittance before we can proceed with extensive hospital care. A 1.5% fee per month will be charged on all accounts that are 30 days past due. A $2 billing fee will also be applied each month. We require a 24 hour notice to change or cancel an office appointment. A 48 hour notice is required for surgical/boarding appointment cancellation and/or rescheduling. We reserve the right to charge a fee for a missed, cancelled or rescheduled appointment without required notification.

By typing my name in this box I acknowledge that I am 18 years of age or older, have read the above financial policy and missed/cancelled or rescheduled appointment policy and will adhere to their terms.*

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Monday	8:00am – 7:00pm
Tuesday	8:00am – 7:00pm
Wednesday	8:00am – 7:00pm
Thursday	8:00am – 7:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 5:00pm
Sunday	8:00am – 2:00pm

Patient History Form

Patient History Form

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