CLIENT INFORMATION

Name *

Primary Phone

Secondary Phone

Email *

PATIENT INFORMATION

Pet Name *

Age or DOB

Breed

Sex

Male
Neutered
Female
Spayed

Species

Dog
Cat
Other

If other, please specify: *

Reason for Scheduling with Internal Medicine

What concerns bring your pet to see us today?

When did you first notice these issues?

Have the signs been:

Improving
Worsening
Staying the same
Intermittent

Has your pet been treated for this problem before?

Yes
No

If yes, please describe (tests, treatments, response):

CURRENT MEDICATIONS & SUPPLEMENTS

Please list all medications, supplements, and preventatives your pet is currently taking (include dose & how often). Please bring all medications with you to each visit with the Internal Medicine team.

Repeater

Medication/Strength

Dose/Frequency

DIET & APPETITE

Current Diet (brand, type, prescription if applicable):

Appetite

Normal
Decreased
Increased
Picky

Any diet changes?

Yes
No

If yes, please explain: *

ENERGY & BEHAVIOR

Energy Level:

Normal
Decreased
Increased

Any weight changes?

Loss
Gain
No Change

Behavioral changes (anxiety, hiding, restlessness, etc):

MEDICAL HISTORY

Known medical conditions:

Previous surgeries or hospitalizations:

Allergies or medication reactions:

VETERINARIAN/CLINIC

Please provide any/all veterinary clinics/hospitals your pet has received care/diagnostics for the current condition. If we have not received your pet's previous medical records from your veterinarian within 48 hours before your scheduled appointment, repeating tests or rescheduling the appointment may be necessary. We appreciate the assistance to make sure we are prepared for your pet's visit.

ADDITIONAL INFORMATION

Is there anything else you feel is important for us to know about your pet or their condition?

GOALS & EXPECTATIONS

What are your goals for today's visit?

Other *

ACKNOWLEDGEMENT

Due to high demand for appointment availability, payment of the exam fee is required at time of scheduling all new client specialty appointments. Clients may reschedule one time with a minimum of 48 hours’ notice. Missed appointments, late cancellations, or additional rescheduling requests will result in forfeiture of the fee.

At time of the visit, full payment is required upon approval of the estimated care. We do not provide billing services, and we do not hold checks. We require a deposit of the lower end of the estimate at the time of admission for hospitalization or outpatient treatment. We accept cash, checks, and credit cards. We offer various independent third party payment plan options. You must apply for and be approved for those options. Please ask one of our staff about applying for the payment options that are available if you are interested. The doctors and staff of City Paws are not authorized to make changes to the hospital’s payment policy.

*

I have read and understand the financial policies of the City Paws. I certify that I am the owner of or the agent of the owner of the aforementioned pet. I further understand that I agree to the terms of payment above.

New Client Questionnairein Oklahoma City, OK

Thank You for Choosing City Paws