Name: Elwood Animal Clinic
Telephone: +1-
Price range: $$

Client Name*

First Last

Cell Phone Number*

Pet Name*

Reason for your pets visit with us today*

Diet Fed*

Medications/Supplements*

Where does your pet primarily stay?*

Indoor
Outdoor
Both

Other Pets in household*

Yes
No

If yes

Dog
Cat
Both

Flea / Tick/ Heartworm Prevention*

Yes
No

Type(s) Given

Vaccines up to date*

Yes
No
Unsure

EMAIL*

Please Check all of the following symptoms your pet is having, and please put how long the symptoms have been going on the line:

Coughing*

Yes
No

For How Many Days

Any History of heart problems*

Yes
No

If yes, is your pet on any medications?

Sneezing*

Yes
No

For How Many Days

Vomiting*

Yes
No

For How Many Days

Any change in Diet or Treats?*

Yes
No

If yes, When did you change diet?

Diarrhea*

Yes
No

For How Many Days

Eating*

Decreased
Normal
Increased

Drinking*

Decreased
Normal
Increased

Activity*

Decreased
Normal
Increased

If your pet is here for another reason not listed above please fill out the following below:

How long has the issue been going on/how long have you noticed the issue/ any other issues to check ?

Photo Consent

We respect your privacy and will never use your pet’s photo without your permission. Names or identifying client information will not be shared.

Do we have your permission to take photos of your pet for use on our website, social media, or clinic materials?*

Yes, I consent to the use of my pet's photo.
No, I do not consent to the use of my pet's photo.

Consent to Release Veterinary Records*

I DO consent to the release of my pet’s records as outlined above.
I DO NOT consent to the release of my pet’s records.

I authorize Elwood Animal Clinic to release my pet’s medical records to other veterinary hospitals, specialists, or animal care providers upon request, as deemed necessary for continuity of care. I understand that records may be sent via fax, email, or other secure electronic means. I also authorize the release of vaccine history and relevant medical information to boarding facilities, grooming salons, training facilities, or city/county animal control, when required.

Name

This field is for validation purposes and should be left unchanged.

Check-In Questionnaire (Elwood)

Please Check all of the following symptoms your pet is having, and please put how long the symptoms have been going on the line:

If your pet is here for another reason not listed above please fill out the following below:

Photo Consent

Our Location

Come Visit Us

Have Questions?
We’ll Reply Quickly.

Check-In Questionnaire (Elwood)

Please Check all of the following symptoms your pet is having, and please put how long the symptoms have been going on the line:

If your pet is here for another reason not listed above please fill out the following below:

Photo Consent

Our Location

Come Visit Us

Have Questions? We’ll Reply Quickly.

Accessibility Tools

Have Questions?
We’ll Reply Quickly.