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?

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?*

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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*