Intake Form

Welcome to Enchanted Mountains Urgent Vet Care! We are excited that you have chosen us to be a part of your pet’s health care. We are dedicated to providing convenient, comprehensive, and cost effective care for your furry family member! This form is intended to collect the information necessary for EMUVC to initiate, populate, and maintain appropriate client and medical records and most importantly to obtain pertinent medical and and historical information about your pet. This form may take some time to answer and we apologize for all the work that goes into getting this done. Just know that this information is important and that we are only collecting it to make sure we have all the information we need to help make your pet feel better.

YOUR PET'S INFORMATION

Has your pet been here before or is this their first visit?(Required)

What is your pet's name?(Required)

How old is your pet or what is their date of birth?(Required)

Is your pet male or female?(Required)

Has your pet been spayed or neutered?(Required)

What species is your pet? Cat? Dog? Something else?(Required)

What breed is your pet? (If your pet is a cat, does it have short, medium or long hair?)(Required)

What color is your pet?(Required)

YOUR INFORMATION

Have you been here before or is this your first visit?(Required)

What is your last name?(Required)

What is your first name?(Required)

What is your street address (not PO box)?(Required)

What is your city, state and zip code?(Required)

What is your e-mail? (We can't send or receive from icloud.)(Required)

What is your phone number? (You can give us more than one, but a mobile phone is preferable.)(Required)

Do we have permission to text you at this number?(Required)

We will only use your number for communication with us regarding the care of your pet.

What is the name of your pet's co-owner (if any)?(Required)

Who is your primary veterinarian? (Please give us the name of the clinic rather than the doctor.)(Required)

PRESENTING COMPLAINT

Why is your pet coming in today? Please give as much detail as possible. When did the symptoms begin? Have they gotten worse? More information is better.(Required)

Is your pet eating normally? If not, how so?(Required)

Is your pet drinking normally? If not, how so?(Required)

Is your pet urinating normally? Less? More? Is it colored differently?(Required)

Is your pet defecating normally? If not, how so?(Required)

Is your pet coughing? How much?(Required)

Is your pet sneezing? How much?(Required)

Is your pet vomiting? How often? What does it look like?(Required)

Is your pet having diarrhea? How often?(Required)

Is your pet drinking or urinating excessively?(Required)

Has your pet recently gotten into trash or any toxin? If the latter, what was it? If it was rat poison, we need to know what the active ingredient was and how much they ingested.(Required)

What year was your pet's last rabies vaccination?(Required)

Is your pet up to date on all other vaccines? If so, list which ones they've received and what year.(Required)

Does your pet have any known allergies?(Required)

Is your pet currently taking any medications? (This means vet-prescribed or OTC medications like aspirin, ibuprofen or Benadryl.)(Required)

Is there any past medical history we should know about including surgeries, injuries or illnesses?(Required)

Should we know anything about your pet's visit today? Are they anxious? Aggressive? Prone to flee?(Required)

Does your pet spend most of their time indoors or outdoors?(Required)

Are your from out-of-state or has your pet recently traveled out-of-state?

How did you hear about us?(Required)

CAPTCHA

700 W STATE ST

(716) 257-4830

7 Days a Week

Intake Form

YOUR PET'S INFORMATION

YOUR INFORMATION

PRESENTING COMPLAINT

Text Now (716) 257-4830