Client Intake Form | Veterinary Emergency and Specialty Centers of New Mexico

Client Information
Name*
First Middle Last
Additional Owner(s):
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone*
Cell Phone*
Email*
Employer*
How did you hear about us?
- Google
- Yellow Pages
- Walk-In
- Friend
Referring Veterinarian:*
Family Veterinarian (if different):
Patient Information
Pet's Name*
Species*
- Canine
- Feline
Breed
Sex*
- Male
- Female
- Male Neutered
- Female Spayed
Birthday or Age:*
Initial Presenting Problem:*
Would it be alright for us to add a picture of your pet on our website/ social media sites? (None of your personal information will be shared besides your pet's name)*
- Yes
- No
Name(s) of Individuals Authorized to Pick Up Patient from VSNM:
Medical History
To aid us in reaching an accurate diagnosis, a complete background on your pet is essential. Please fill out all pages of the following questionnaire to the best of your ability.
Pet's Name:*
How long have you owned your pet?*
Where was your pet obtained?*
Does your pet ever go outside?*
- Yes
- No
Is your pet allowed to roam free?*
- Yes
- No
Has your pet been boarded, hospitalized, or at the animal shelter recently?*
- Yes
- No
Are there any other animals in your household?*
- Yes
- No
Vaccination History
When was your pet last vaccinated against:
Dog: Distemper/Parvo/Corona?
Dog: Leptospirosis?
Dog: Rabies?
Dog: Bordatella?
Cat: Panleukopenia/ Rhinotracheitis/ Calicivirus?
Cat: Rabies?
Cat: Feline Leukemia Virus (FeLV)?
Cat: Feline Immunodeficiency Virus (FIV, feline AIDS)?
Prior to this illness, has your pet been treated for any major medical problems?*
- Yes
- No
If your pet is neutered/ spayed, what was his/ her age when this surgery was performed?
Has your pet undergone any other surgery?*
- Yes
- No
If your pet is female has she had any litters?*
- Yes
- No
If your pet is female and not spayed, when was her last heat cycle?
If your pet is female, has there been any abnormal vaginal discharge?*
- Yes
- No
Is your pet now taking medication to prevent heartworm disease?*
- Yes
- No
Is your pet now taking medication to prevent fleas?*
- Yes
- No
Is your pet now taking medication to prevent ticks?*
- Yes
- No
Is your pet now taking medication to prevent ticks?*
- Yes
- No
Has your pet traveled out of New Mexico?*
- Yes
- No
What does your pet normally eat?*
Approximately how much and how often does your pet eat?*
Is your pet ever fed table scraps?*
- Yes
- No
Has your pet's appetite increased or decreased recently?*
- Increased
- Descreased
- No Change
Is your pet drinking more water than usual?*
- Yes
- No
- No Change
Is your pet urinating more frequently than usual?*
- Yes
- No
Is your pet straining to urinate?*
- Yes
- No
Is there any blood or discoloration of your pet's urine?*
- Yes
- No
Has your pet been vomiting?*
- Yes
- No
Have there been any recent changes in the frequency, amount or color of your pet’s bowel movements?*
- Yes
- No
Is your pet straining to defecate?*
- Yes
- No
Has your pet been itching/ scratching?*
- Yes
- No
Has your pet had any discharge from the eyes or nose?*
- Yes
- No
Has your pet been sneezing excessively?*
- Yes
- No
Has your pet been coughing or showing difficulty breathing?*
- Yes
- No
Has your pet had any seizures or convulsions?*
- Yes
- No
Has your pet shown any changes in attitude or behavior?*
- Yes
- No
Has your pet lost stamina recently?*
- Yes
- No
Has your pet's walk changed?*
- Yes
- No
Have you noticed any swelling or masses?*
- Yes
- No
Has your pet had unusual/unexpected reactions to medications?*
- Yes
- No
What medications is your pet currently receiving?*
What is your primary concern about your pet?*
File Upload
Treatment Authorization and Information
I hereby authorize VSNM practices to perform medical and initial diagnostic/surgical procedures in my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants.If I have been referred to this hospital by another veterinarian, I understand that they will require a summary of the care and treatment provided by the VSNM practices in order to ensure that my pet’s care can be continued without interruption. I also understand that VSNM considers the identification of a referring veterinarian by me to be my authorization to release records and information to that veterinarian. We are leaders and teachers in the veterinary medical field, thus case information and/or photos may be used in teaching, forms, continuing education, web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; patient confidentiality (names withheld) will be maintained.In the event this animal transfers to ownership, I authorize release of medical information to the new owner, should they request it.
Financial Policy
Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. You may pay by cash, personal check (with proper identification), or accepted credit cards. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory.In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. A service fee of $3.00, and 1.5 % of the outstanding balance will be charged to your account monthly if not paid in full. All returned checks will incur a charge of $35.00 and may be referred to the District of Attorney for collection.
Authorization
I understand that I (the owner or agent) am financially responsible to the applicable VSNM practice(s) for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations.
Digital Signature:*
Type your full legal name above
Date*
Date Format: MM slash DD slash YYYY

Client Information

Patient Information

Medical History

Vaccination History

Treatment Authorization and Information

Financial Policy

Authorization