Pet Medical History Form - Chester Valley Veterinary Hospital

Name *

First

Last

Email *

Phone *

Spouse/Secondary Name

First

Last

Spouse Phone

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you a new or existing client? *

New client
Existing client

Check all that apply

Military
Policeman
Fireman
Senior Citizen

How did you hear about us?

Yellow Pages
Internet
Drive By/Sign
Friend

Friend's Name *

(Please specify the referrer’s name so we can send a thank you gift)

Pet's Name *

Date of Birth or Age *

Species *

Breed *

Sex *

Male
Female

Fixed *

Yes
No

Color/Description *

Microchip Number

Name of Previous Veterinary Office/Vaccine Clinic

Previous Veterinary Office/Vaccine Clinic's Phone Number

This is so we can get records if needed

Primary contact for visit *

First

Last

Primary contact for visit phone *

Person bringing in pet for visit *

First

Last

Phone *

Reason for visit *

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

Medical History

See if your pet qualifies for "Sick/Urgent Care" Walk Ins or "Wellness" Walk Ins.

Excessive Thirst *

Yes
No

How long?

Excessive Drooling *

Yes
No

How long?

Lethargic *

Yes
No

How long?

Concerns with Eating and drinking? *

Yes
No

How long?

Painful *

Yes
No

How long?

Wounds *

Yes
No

Where?

When did it happen?

Excessive Panting *

Yes
No

How long?

Labored Breathing/ Wheezing *

Yes
No

How long?

Sneezing/ Coughing/ Hacking *

Yes
No

How long?

Balding/ Losing Hair *

Yes
No

How long?

Where?

Weight Gain/ Loss *

Yes
No

How long?

Foul Breath *

Yes
No

How long?

Difficulty Urinating *

Yes
No

How long?

Excessive Urination *

Yes
No

How long?

Change in Urine Color/ Odor *

Yes
No

How long?

Urinating outside of the litter box (cat)

Yes
No

How long?

Urinating in the house (dog)

Yes
No

How long?

Dirty/ Smell from Ears *

Yes
No

How long?

Scratching Ears/ Shaking head *

Yes
No

How long?

Discharge from eyes *

Yes
No

How long?

Squinting eyes *

Yes
No

How long?

Vomiting (Food/ Water/ Yellow Bile) *

Yes
No

How long?

How many times per Day/Week/Month

Diarrhea (Liquid/Soft/Bloody) *

Yes
No

How long?

How many times per Day/Week/Month

Lame or Limping *

Yes
No

How long?

New or Unusual Lumps *

Yes
No

Where?

How long?

You qualify for a "Wellness" walk in.

You qualify for a "Sick/Urgent Care" walk in.

Rabies Questions

Does your pet have a current Rabies vaccine *

I have a current Rabies Certificate in hand for when I am seen and if it is expired I understand my pet will be vaccinated during visit for a fee.
My pet’s Rabies vaccine is expired and will need to be revaccinated during visit for fee.
My pet is not old enough for a Rabies vaccine (less than 14 weeks old).
My pet received Rabies Vaccine at CVVH and if it is expired I understand that my pet will be revaccinated during the visit for fee.

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

Date of Departure *

Transportation *

Flying
Driving
Ferry
Train

Flying generally requires health certificates to be performed within 10 days of flight.

Driving health certificates are good for 30 days from issue.

Travel purpose *

Vacationing
Moving

Are you traveling with your pet? *

Yes
No

Repeat Your Name *

First

Last

Person Dropping Pet Off at Airport Name *

First

Last

Your Phone *

Person Dropping Pet Off at Airport Name 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

Is your pet on any medications? *

Yes
No

If your pet is on any medications, vitamins, supplements, or Special Diets please bring a detailed list of what the name, strength, dose, and frequency. This is extremely important, even if your pet is on medications we prescribed.

Please list medications and dosage: *

Other

Has Your Pet Been to the Lower 48 *

Yes
No

When?

Additional information you think is important for us to know:

Has our staff spoken to you about Geriatric blood work? *

Yes
No

If not and you are interested, please ask the front desk or the doctor.

Geriatric Ages

Cats: Over 10-12 Years old
Small-Med. mixed breed dogs: Over 10 Years old
Large breeds (Over 70lbs) and/or Purebred dogs: Over 8 Years old

Upload Relevant Medical Records

Click or drag files to this area to upload. You can upload up to 10 files.

Signature *

Date *

Complete your medical history form online!

Medical History

Rabies Questions

Health Certificate

Current Medications

Other