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Home » Canine/Feline Intake Form

Canine/Feline Intake Form

Date

MM slash DD slash YYYY

Does your pet have insurance?(Required)

Yes

What insurance?(Required)

Can we post pictures and/or videos of your pets on our social media?(Required)

Yes

Client Name(Required)

First

Last

Client Date of Birth(Required)

MM slash DD slash YYYY

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Are you a new client?(Required)

Yes

How did you hear about us?(Required)

How may we contact you?(Required)

Phone

Text

Pet Information

Your Pet's Name(Required)

Breed and Color(Required)

Age/DOB(Required)

Sex(Required)

Male

Female

Spayed

Neutered

What is your pets’ present concern today?(Required)

To provide a relaxed and personalized atmosphere with caring doctors and staff who maintain the highest standards of medicine. If, at any time during your relationship with our hospital you feel there is something that needs to be brought to our attention, in order for us to serve pets and their people more efficiently, please let us know.

Visit Information

What is the primary reason for your pets visit today?(Required)

Is your pet eating and drinking normally?(Required)

Yes

How long?(Required)

Has your pet been coughing, sneezing, vomiting, or having diarrhea?(Required)

Yes

How long?(Required)

Is your pet urinating and defecating normally?(Required)

Yes

How long?(Required)

Diet information: Please include the brand name, how much, and how often they eat.(Required)

Is your pet currently on any flea or tick preventatives?(Required)

Yes

Which one(s)?(Required)

Has your pet had a heartworm test?(Required)

Yes

When?(Required)

Is your pet currently taking any medication(s)?(Required)

Yes

Which medication(s)?(Required)

Does your pet have any known allergies?(Required)

Yes

what allergies?(Required)

While your pet is here, can they have treats to make their visit more pleasant?

Yes

(ex:peanut butter)

Pet Traveling Conditional Section

Is your pet traveling?(Required)

Yes

Pet Name(Required)

D.O.B(Required)

Color(Required)

Breed(Required)

Name of person travelling with/shipping pet(Required)

Phone Number(Required)

Alternate Phone Number

Email(Required)

Address in San Diego where pet is leaving from(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Departure Date(Required)

MM slash DD slash YYYY

How is pet travelling(Required)

Air

Car

Cargo

Transport Service

Name of airline or Transport Service driving pet(Required)

Name of person receiving pet(Required)

Address pet is travelling to(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Phone Number(Required)

Email(Required)

Notes

Please remember to bring medical records or any pertinent information. Please reference www.aphis.usda.gov to view requirements for your destination.

Record Release Consent

RECORD RELEASE CONSENT(Required)

Please initial here to authorize the release of your pet’s medical records for insurance, referrals, or to other hospitals in case of emergency.

OWNER RELEASE: My signature below acknowledges I am the legal owner of the above pet(s). I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on this sheet. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise completed. I understand that veterinary service is not provided during the night time hours. Thank you for choosing Otay Pet Vets!

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Come See Us

2015 Birch Rd
Suite 107
Chula Vista, CA 91915

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Services

2015 Birch Rd
Suite 107
Chula Vista, CA 91915

Home
About Us
Services
Exotic Care
Urgent Care
Contact Us
Online Store

Business Hours

Monday

7:00am - 7:00pm

Tuesday

7:00am - 7:00pm

Wednesday

7:00am - 7:00pm

Thursday

7:00am - 7:00pm

Friday

7:00am - 7:00pm

Saturday

7:00am - 7:00pm

Sunday

9:00am - 6:00pm

For after hours ER, please visit your nearest veterinary emergency hospital.

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