Public Clinic Intake Form

NOTE: This form IS NOT for appointment booking.

Your First Name *

Your Last Name *

Email Address *

Phone Number *

Appointment Date *

Appointment Time *

Name of person bringing animal (if different)

Phone number of animal handler (if different)

Animal Name *

Species *

Breed. In most cases this will be DOMESTIC SHORTHAIR or DOMESTIC LONGHAIR. Please select one of these. *

Color *

Size *

Gender *

Animal Birthdate (estimate is fine) *

Spayed or Neutered? *

Date of spay/neuter. Leave blank if animal is not spayed/neutered

Place where spayed/neutered. Put "N/A" if animal is not spayed/neutered *

Microchip number. LEAVE BLANK IF NO CHIP

When was the cat rescued? *

Weight of Animal (estimate ok)

Date of most recent flea treatment. Put N/A if none *

Type or brand of most recent flea atreatment. Put N/A if none *

Dates of deworming medications given. Put N/A if none *

Types of deworming given. Put N/A if none *

Date of last vet visit (if known)

Please list most recent vaccines and dates. Put N/A if none *

Other medical information: dates of tests and results, bloodwork, medications, etc

Other notes about the animal

Is the cat handeable and will be okay in an environment where it can see and hear other cats? *

To your knowledge, has the cat bitten any vet? *

Is the cat eating and drinking normally.

Any recent noticeable change in weight? *

What is the cat currently eating?

Has there been any recent change in energy level? *

Any discharge from eyes? *

Which eye?

How long has there been discharge?

What color is discharge?

Is cat rubbing eyes?

Can you place medication in the cat's eyes?

Is the cat scratching one or both ears? *

Any discharge from nose? *

Which nostril?

How long has there been discharge?

What color discharge?

Is there blood in discharge?

How is the cat's breathing?

Is the cat vomiting? *

When did it start?

How many times a day?

What is in the vomit?

Any plants the cat may be chewing or eating?

Do you need to coax the cat to eat?

Is cat straining to poop when they vomit?

Does the cat cough while vomiting?

Does the cat have diarrhea? *

When did it start?

How many times a day?

Is there blood? Is it thick or thin?

Is there mucous?

Are the stools watery or soft?

Is the cat straining to defecate?

Has there been a change in diet or new treats added?

is there stress in the home?

Do any other pets in the home also have diarrhea?

Can you medicate the cat? (Pick all that apply) *

Any additional medical concerns?

Services Requested. Select all that apply. *