Returning Clients Form - Mount Joy Animal Clinic

Returning Client Intake Form

Please fill in the information below and our team will be in touch to book your next appointment.

We’re looking forward to seeing you again soon!

Returning Clients

Today's Date:(Required)

Full Name(Required)

Co-Owner's Full Name (if applicable)

Phone Number(Required)

Email(Required)

Pet's Name(Required)

Main concern(s) for visit?(Required)

When was the last time you remember your pet's health being normal?

Pet's current diet (food brand & amounts)(Required)

Does your pet get human food? if so, which foods?

Nail trim?

Yes

Check anal glands?

Yes

How is their behaviour?(Required)

Normal

Lethargic

Increased

How is their eating?(Required)

Normal

Decreased

Increased

How is their urination?(Required)

Normal

Decreased

Increased

How is their bowel movement?(Required)

Normal

Abnormal

When was their last bowel movement?(Required)

Mouth/Teeth: Are any of these symptoms present?

Bleeding mouth/teeth

Growths in mouth

Broken teeth

Loose teeth

Nose: Are any of these symptoms present?

Nasal disharge

Sneezing

Eyes: Are any of these symptoms present?

Redness

Swollen

Discharge

Inflamed

If yes, which eye(s)?

Right

Left

Both

Ears: Are any of these symptoms present?

Redness

Swollen

Itchy

Inflamed

If yes, which ear(s)?

Right

Left

Both

Breathing: Are any of these symptoms present?

Rapid Breathing

Difficulty Breathing

Coughing

Gastrointestinal: Are any of these symptoms present?

Excessive gas

Vomiting

If vomiting, frequency and contents?

Genitals: Are any of these symptoms present?

Discharge

Blood in urine

Swollen

Itchy

If blood in urine, when?

Coat/Skin: Are any of these symptoms present?

Licking

Scratching

Masses

Lymph Nodes Swollen

If there are masses, where are they located?

Legs/Paws: Are any of these symptoms present?

Limping

Broken Nails

Ingrown Nails

If limping, for how long?

Any other concerns?

What language do you prefer the doctor speak?

English

Mandarin

Cantonese

We look forward to welcoming you!

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