Client/Patient Intake

Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Apartment Number (If this is an apartment address)

Primary Phone*

Secondary Phone

Owner's Date of Birth*

Email*

Is There a Second Owner You Would Like to List?

Name

First Last

Email

Phone

How did you hear about us?*

Family or Friend
Referred by Regular Veterinarian
Referred by Another ER Clinic
Internet Search
Shopping Center Sign
Yellow Pages
Previous Visit
Other

Pet Information

Pet's Name*

Pet's Date of Birth*

Species*

Canine
Feline
Other

Breed*

Weight

Color*

Sex*

Male
Male/Neutered
Female
Female/Spayed

Currently Vaccinated?*

Yes
No

How is the pet's temperament at the vet?*

Friendly
Shy/Nervous
Human Aggressive/Needs Muzzle
Animal Aggressive
Unsure
Other

What do you feed your pet?*

Does your pet have any allergies?*

What is the name of your pet’s primary care veterinarian?*

Where is the primary care veterinarian?*

What is the problem you are being seen here for today?*

Does your pet have any other medical problems? Please explain.

Please list any medications your pet is taking.

Do you have pet insurance?*

Yes
No

If yes, which company?

Medical Records Release

I verify that I understand that Beacon Veterinary Specialists may be required to provide medical records to the other veterinary providers treating my pet as well as to insurance companies providing coverage for my pet(s) that are listed above. I further understand that Beacon Veterinary Specialists may be required to provide records to Animal Welfare and/or other governmental agencies.

I acknowledge the Medical Record Release. Please Initial Here*