Patient Intake Form

Intake Form for Scheduled Appointment
NOTE: This form is only to be completed for a Wellesley Vet Clinic patient that has a scheduled appointment with us.
Client's Information
Please list the name & cell number of the Owner or Authorized Agent that will be attending the appointment.
Name*
First Last
Cell Phone*
Pet Information
Pet's Name*
Please list any specific concerns or questions you would like addressed during the appointment.
Does your pet have any allergies?
Has your pet ever reacted to a vaccination?
How is your pet's appetite?
What food are you currently feeding your pet? How often? How much daily?
What treats do you give your pet? How much and how often?
May we give your pet treats during the appointment?
Has there been any change in your pet's water intake? If so, for how long and is it increased or decreased?
How is your pet's energy level? Has there been any change in it?
Has there been any vomiting or diarrhea? If so, please provide details.
Has there been any coughing or sneezing? If so, please provide details.
Does your pet's urination seem normal? Do you have any concerns?
Is your pet currently on any medications or supplements? If so, please provide details.
Has you pet been boarding or travelled recently? If so, please provide details.
Are there any mobility or lameness concerns with your pet?
Are there any skin lesions or lumps/bumps on your pet?

Pet feeling blue? Use our online symptom checker. Pet Health Checker

Intake Form for Scheduled Appointment