ER Intake Form

Please complete the intake form below:

ER Intake Form

Owner Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Patient Name:(Required)

Age:(Required)

Breed:(Required)

Gender:(Required)

What is the reason for visiting the ER? Please describe the problem in as much detail as possible.(Required)

Does your pet have any other known medical problems? If so, please list them below.(Required)

What medications is your pet taking? Please list the name of the medication, tablet size or liquid concentration (ex: 20 mg tablets), dose and frequency of administration.(Required)

Is your pet on flea/tick/heartworm prevention? If so, what kind, and seasonally or year round?(Required)

Is your pet taking any supplements, herbs, or vitamins? If so, please list the name, brand, and dose.(Required)

Has your pet ever taken pre-visit medications to reduce their anxiety at the vet? If so, what medication(s) and dose(s)?(Required)

What brand of food is your pet eating, and how much do they eat per day? Also, please describe any treats they receive on a regular basis.(Required)

Has your pet ever had surgery, apart from their spay or neuter? If so, what kind?(Required)

To your knowledge, has your pet generally handled sedation and anesthesia well in the past? If not, what concerns were there?(Required)

Does your pet have any known allergies to foods or medications? If so, what are they?(Required)

Has your pet ever had a blood transfusion? If so, do you know their blood type?(Required)

What veterinary practices or hospitals has your pet been to (names and contact information please)?(Required)

Apart from MA, what states and countries has your pet traveled to or lived in?(Required)

Do you have other pets? If so, how many and what kind?(Required)

Is there anything else we should know about your pet prior to your appointment?(Required)

Please read and acknowledge the following:

Due to space and liability constraints, we are not able to have clients remain with patients during examinations, vitals checks, treatments, and procedures. For clients who prefer to stay with their pets throughout the entire treatment process, we recommend finding a VEG (https://www.veterinaryemergencygroup.com/) location.

Read and acknowledged(Required)

Acknowledged