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Current Patient History Form
PLEASE FILL OUT THE INFORMATION BELOW FOR THE PET THAT HAS THE APPOINTMENT. Provide as much information as you can about the patient.
Drop off appointment:
Please arrive 10 minutes before your appointment time. If your pet is scheduled for a routine annual exam, Seville Veterinary Hospital recommends yearly blood screen, heartworm test, stool checked, annual heartworm prevention, and immunization based on the need and lifestyle our your pet. You will be provided with a HealthCare Plan for your pet's annual preventatives. For preventive and medical appointments please bring in your pet's stool and urine sample. If your pet is on medication or supplements please bring them to the appointment.
Notifying us of your arrival:
Please call our office or send us a text (480-279-2831) to let us know your pet has arrived for their appointment.
Drop Off preference:
Please inform our client specialist of your preference for your pet's drop-off appointment.
Outside Intake
(Please provide us with your vehicle color, make, and model). After checking in a member of our nursing team will be bringing your pet into the office for their appointment. Please have the patient on a leash or carrier before drop off.
In-Office Intake
Please have the patient on a leash or in a carrier before coming into the practice. One of our Client Care Specialists will escort you into an exam room.
Owner bringing the patient in for appointment
*
First
Last
Best Contact Phone Number:
*
Pet's Name
*
Date of Birth or Age
Date Format: MM slash DD slash YYYY
Sex
Male
Female
Sex
Spayed
Neutered
Unaltered
Species
Dog
Cat
Breed
Color
Microchip Number (If you have one) (Please fill in if the patient was not microchipped at SVH)
When was your pet last vaccinated (Please fill in if the patient was not vaccinated at SVH)
Does your pet have any known allergies?
Yes
No
If yes, please indicate
Does your pet have health insurance?
Yes
No
If yes, what is the insurance company?
Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.
For how long has your pet been experiencing the problem described above?
Has your pet had any coughing?
Yes
No
If yes, for how long? Please provide more details.
Has your pet had any sneezing?
Yes
No
If yes, for how long? Please provide more details.
Does your pet have any nasal discharge?
Yes
No
If yes, for how long? Please provide more details.
Has your pet been vomiting?
Yes
No
If yes, for how long? Please provide more details.
Has your pet had diarrhea?
Yes
No
If yes, for how long? Please provide more details.
Does your pet’s stool look normal in color?
Yes
No
If no, is it black or bloody?
Yes
No
Has your pet been drinking more?
Yes
No
Has your pet been urinating more?
Yes
No
Have you seen your pet's urine?
Yes
No
If yes, what was the color and amount?
Has your pet's appetite changed?
Yes
No
If yes, for how long? Please provide more details.
When was the last time you saw a bowel movement and what did it look like?
What is the name of the food you feed your pet? Is it canned, dry or both? Specifically, what is the volume of food and treats you are feeding per day?
Is your pet lethargic (not active)?
Yes
No
If yes, for how long? Please provide more details.
Is your pet here because it is limping?
Yes
No
If yes, can you describe what happened or when the lameness started and on which leg?
Please list all medications and supplements/vitamins (name, strength, and amount) your pet is on and when they were last given:
Any additional information that you feel would be helpful in treating your pet. We will do our best to have your pet seen and communicate a plan as quickly as possible
How would you prefer to receive bloodwork and or any other test results for your pet(s)?
Phone
Text
Email
PLEASE FILL IN THE INFORMATION BELOW IF APPLICABLE
List any other veterinary provider who have treated the patient in the last 12 months.
Do you give Seville Veterinary Hospital permission to contact the veterinary practice above for your pet (s) records?
Yes
No
I will bring the records with me for you to copy
Please check off the facilities you give SVH consent to release your pet (s) medical records and vaccination records to:
Emergency Room
Speciality Center
Boarding/Grooming
Please list any party that you do not want SVH to release records to:
About Us
Services
Medical Boarding
Laser Therapy
Acupuncture Holistic Medicine
Pet Resources
Testimonials
Make An Appointment
Team
Employment Opportunities
New Clients
Links
Online Forms
Take A Tour
Payment Options
Pet Health
Pet Health Library
How-To Videos
Pet Insurance Info
Pet Health Checker
News
Contact
Pet Portal
Store
Promotions
