Patient Intake Form

We can’t wait to meet your furry friend! Completing our patient intake form ahead of time ensures a smooth check-in process and allows our veterinary team to review your pet’s medical history before your visit.

First Name

Last Name

Co-owner First Name

Co-owner Last Name

Address

City

State

Zipcode

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

Preferred Contact Method

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Relationship

Pet's Name

Species

Gender

Breed

Age/DOB

Color/Markings

Is This Pet Spayed/Neutered?

Is This Pet Microchipped?

Is This Pet Current on Vaccinations?

Known Allergies or Sensitivities: (type none if applicable)

Current Medications or Supplements: (type none if applicable)

Chronic Conditions (e.g., diabetes, arthritis): (type none if applicable)

Previous Surgeries or Hospitalizations: (type none if applicable)

Behavior Concerns (e.g., fear, aggression): (type none if applicable)

Previous Vet Clinic

Previous Vet Clinic Phone

Previous Vet Clinic Email

May we contact them for medical records?

Consent for Treatment

I authorize the veterinarians and staff of Peak Veterinary Hospital to examine, diagnose, and treat my pet. I understand that a treatment plan and cost estimate will be provided when appropriate. I agree to pay in full for all services rendered at the time of discharge unless other arrangements have been made in advance.

Printed Full Name

Date