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
*
Cat
Breed. In most cases this will be DOMESTIC SHORTHAIR or DOMESTIC LONGHAIR. Please select one of these.
*
Domestic Short Hair
Domestic Medium Hair
Domestic Long Hair
Unknown
Other
Color
*
Amber
Black
Black and Brown
Black and Tan
Black and White
Black Tortie
Brown
Brown and Black
Brown and White
Brown Tabby
Brown Tabby and White
B & W Tuxedo
Calico
Chocolate Tortie
Cinnamon Tortoiseshell
Cream
Cream Orange
Cream Tabby
Dilute Calico
Dilute Torbie
Dilute Tortie
Ginger
Golden
Grey
Grey and White
Grey Tabby
Grey Tabby and White
Lilac
Lilac Tortie
Orange
Orange and White
Orange Tabby
Seal
Siamese
Silver
Tabby and White
Tabico
Tan
Tan and Black
Tan and White
Tiger Cali
Torbie
Tortie
Tortie and White
Tricolour
Various
White
White and Black
White and Brown
White and Grey
White and Tabby
White and Tan
White and Torti
Size
*
Large
Medium
Small
Very Large
Gender
*
Female
Male
Unknown
Animal Birthdate (estimate is fine)
*
Spayed or Neutered?
*
Yes
No
Unknown, please check
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?
*
No
Yes
To your knowledge, has the cat bitten any vet?
*
No
Yes
Is the cat eating and drinking normally.
No
Yes
Any recent noticeable change in weight?
*
Weight Loss
Weight Gain
No Noticeable Change
What is the cat currently eating?
Has there been any recent change in energy level?
*
More active than normal
More tired than normal
Normal energy level
Any discharge from eyes?
*
No
Yes
Which eye?
Left Eye
Right Eye
Both Eyes
How long has there been discharge?
What color is discharge?
Clear
Yellow/Green
Is cat rubbing eyes?
No
Yes
Can you place medication in the cat's eyes?
No
Yes
Is the cat scratching one or both ears?
*
No scratching
Left ear
Right ear
Both ears
Any discharge from nose?
*
No
Yes
Which nostril?
Left Nostril
Right Nostril
Both Nostrils
How long has there been discharge?
What color discharge?
Clear
Yellow/Green
Is there blood in discharge?
Left Nostril
Right Nostril
Both Nostrils
No Blood
How is the cat's breathing?
Breathing normally
Breathing fast
Breathing heavy
Open mouth breathing
Is the cat vomiting?
*
No
Yes
When did it start?
How many times a day?
What is in the vomit?
Any plants the cat may be chewing or eating?
No
Yes
Do you need to coax the cat to eat?
No
Yes
Is cat straining to poop when they vomit?
No
Yes
Does the cat cough while vomiting?
No
Yes
Does the cat have diarrhea?
*
No
Yes
When did it start?
How many times a day?
Is there blood? Is it thick or thin?
Is there mucous?
No
Yes
Are the stools watery or soft?
Watery
Soft
Normal
Is the cat straining to defecate?
No
Yes
Has there been a change in diet or new treats added?
No
Yes
is there stress in the home?
No
Yes
Do any other pets in the home also have diarrhea?
No
Yes
Can you medicate the cat? (Pick all that apply)
*
No
Pills
Liquid
in Food
Any additional medical concerns?
Services Requested. Select all that apply.
*
$25 FIV/FeLV Snap Test
$10 FVRCP
$10 Rabies
$5 Strongid
$15 Revolution
$15 Microchip
$2 Nail Trim
$20 Ear mite check (includes treatment if needed)
$15 ear cleaning
Fecal exam $50 (bring sample)
None