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Indian Tree Patient History Form

1. Your Name, First and Last

2. Phone Number

3. Email Address This question requires a valid email address.

4. Your Pet's Name

5. What are we seeing your pet for today?

6. What are you feeding your pet (brand name and type if possible)? How much are you feeding and how often?

7. Is your pet coughing?

8. Is your pet sneezing?

9. Is your pet vomiting?

10. Does your pet have diarrhea?

11. Is your pet eating?

12. Is your pet drinking water?

13. Does your pet have any new lumps or bumps?

14. How is your pet's mobility?

15. If your pet is a cat, are they using the litter box appropriately?

16. If your pet is a cat, are they indoor/outdoor?

Indoor
Outdoor

17. Are you giving medications to your pet?

18. If yes, what medications are you giving? Please list medication name, dose and frequency.

19. Is your pet on Flea and Tick prevention?

If yes, which brand are you giving?

20. Is your pet on Heartworm prevention?

If yes, which brand are you giving?

21. Are there any additional services you would like at your visit? There may be additional fees associated with these services.

22. Social Media Release: I hereby grant Indian Tree Animal Hospital permission to use my pet’s photo in any and all of it's publications, including social media profiles, without payment or other considerations. If yes, please initial:

Please check the box below to proceed.