Oncology Intake Form

Schedule Your Visit: 413-614-0039

Then complete the intake form below:

Oncology Intake Form

Owner Name:(Required)

First Last

Owner Email:(Required)

Owner Phone:(Required)

Patient Name:(Required)

Age:(Required)

Breed:(Required)

Gender:(Required)

What is your pet’s cancer diagnosis, or the primary reason for your oncology consultation?(Required)

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

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

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)

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

Do you have other pets?(Required)

Yes

If so, how many and what kind?

Please describe your pet’s lifestyle (ex: how much time they spend indoors vs. outdoors, what kind of exercise they get, what their daily routine is).(Required)

Do you have any specific questions for the oncology team that we should know about up-front?

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