Medical History Form Online – Chester Valley Veterinary Hospital

Your Name *

First

Last

Pet's Name *

Species *

Breed *

Sex *

Female
Male

Fixed *

Yes
No

Email *

Single Reason for Visit *

Excessive Thirst? *

Yes
No

How Long has This Been Happening? *

Discharge from Eyes? *

Yes
No

How Long has This Been Happening? *

Squinting eyes? *

Yes
No

How long has this been happening? *

Has your Pet Been to the Lower 48? *

Yes
No

When? *

Was Pet on Preventatives? *

Yes
No

Does your Pet Have Diarrhea? *

Yes
No

What Kind of Diarrhea? *

Liquid
Soft
Bloody

How Long? *

How Often? (copy) *

Is Your Pet Vomiting? *

Yes
No

What Kind of Vomit?

Food
Water
Bile
Other

How Long? *

How Often? *

Does Your Pet Have Excessive Drooling? *

Yes
No

How Long? *

Does Your Pet Have Foul Breath? *

Yes
No

How Long? *

Is Your Pet Experiencing Lame Liming? *

Yes
No

How Long? *

Is Your Pet Lethargic? *

Yes
No

How Long? *

Does Your Pet Have Difficulty Urinating? *

Yes
No

How Long? *

Has Your Pet Experienced Weight Gain/Loss? *

Yes
No

How Long? *

Is Your Pet Eating/Drinking Well? *

Yes
No

How Long? *

Is Your Pet Experiencing Excessive Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Poor Balance? *

Yes
No

How Long? *

Is Your Pet Experiencing Pain? *

Yes
No

How Long? *

Has There Been Change in Urine? (Color/Odor) *

Yes
No

How Long? *

Has There New or Unusual Lumps? *

Yes
No

Where? *

How Long? *

Are There Any Wounds? *

Yes
No

Where? *

When Did it Happen? *

Has your Pet Experienced Inappropriate Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Balding/Losing Hair? *

Yes
No

How Long? *

Where? *

Is Your Pet Experiencing Excessive Panting? *

Yes
No

How Long? *

Does Your Pet Have Dirty/Smelly Ears? *

Yes
No

How Long? *

Is Your Pet Experiencing Sneezing/Coughing/Hacking? *

Yes
No

How Long? *

Is Your Pet Experiencing Labored Breathing/Wheezing? *

Yes
No

How Long? *

Is Your Pet Scratching Ears/Shaking Head? *

Yes
No

How Long? *

Is Your Pet Current on Rabies? *

Yes
No

*Must be able to provide proof today.

Additional Information You Feel We Should Know

Do you think it is possible that your pet will bite or injure you while in the vet clinic? Please let us know so we can have staff prepared to help. *

Yes
No

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Health Certificate

Are you being seen for a "Travel Certificate" or "Health Certificate" to drive across the boarder or to fly on a plane? *

Yes
No

Alaska Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Destination Address *

Address Line 1

Address Line 2

City

State

Zip Code

Transportation *

Flying
Driving
Ferry
Train

Travel Purpose *

Vacationing
Moving

Are You Traveling with Your Pet? *

Yes
No

Repeat Your Name *

First

Last

Your Phone *

Person Dropping Pet Off at Airport Name *

First

Last

Person Dropping Pet Off at Airport Phone *

Are you interested in Anxiety medication today? *

Yes
No

Are you interested in Flea/Tick/Heartworm preventatives today? *

Yes
No

Has your pet been to the lower 48 before? *

Yes
No

Current Medications and Supplements

Current Medications/Herbal Supplements

Other

Recent Emergency Visits? Where Was Your Pet Seen?

Primary Contact Today (Name) *

Primary Phone Today *

Photo/Video Release: I hereby grant permission to the rights of my pet’s image, likeness and sound of his/her voice as recorded on audio or video without payment or any other consideration to Chester Valley Veterinary Hospital. I understand that my pet’s image may be edited, copied, exhibited, published or distributed and waive any right to royalties or other compensation arising or related to the use of my pet’s image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. *

Permission granted
Permission denied

Treatment Authorization/Payment Authorization: I hereby authorize Chester Valley Veterinary Hospital’s doctor(s) and staff to examine my pet(s) and to discuss findings with me or an authorized representative. I understand that I am entitled to an estimate of charges for the care and treatment of my pet(s). I am also aware that regardless of my decision to proceed with the estimated treatment or not I am responsible for an exam fee. I hereby consent to the care and treatment of my pet(s) by the staff at Chester Valley Veterinary Hospital. I give my permission to the administration of anesthesia and surgical procedures as seen fit by the physical in the event of an emergency as well as in the treatment of my pet(s). I understand that an itemized receipt will be presented to me upon the release of my pet(s). I take full financial responsibility of all incurred charges for my pet(s). I also understand that full payment is expected before said pet(s) is released to me. I fully understand that any pet(s) brought to Chester Valley Veterinary Hospital by the above person/persons or authorized representative will be considered abandoned, if the animal(s) is not collected within 10days of written notice to the above address. Upon which time Chester Valley Veterinary Hospital has the rights to adopt it out, sell, or euthanize without prejudice to its claims for fees or services rendered. *

I have read and understand

No Show/Cancellation Policy: I hereby understand that Chester Valley Veterinary Hospital requires all appointments be canceled 2 hours prior to your scheduled appointment. Failure to call and cancel an appointment or arriving 5 minutes late to an appointment will be deemed a “No Show.” A cancellation without appropriate notice or no-show appointment will incur a fee at Chester Valley Veterinary Hospital’s discretion and can result in the refusal of service at this practice. *

I have read and understand

Signature *

Date *