Patient Check-In "*" indicates required fields HAVE YOU BEEN TO OUR HOSPITAL BEFORE?* Yes No OWNER FIRST and LAST NAME* First Last PATIENT NAME* PATIENT GENDER*Intact Male (NOT Neutered)Intact Female (NOT Spayed)Neutered MaleSpayed FemalePATIENT DATE OF BIRTH* Month Day Year SPECIES*CanineFelineOtherBREED* COLORS/MARKINGS* HOME ADDRESS* Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PHONE NUMBER*EMAIL ADDRESS* PRIMARY CARE VETERINARIAN / REFERRING VETERINARIAN* PRIMARY CONCERN*DURATION of SYMPTOMS*TREATMENTS PROVIDED AT HOME*SELECT ALL SYMPTOMS THAT APPLY* Vomiting Diarrhea Coughing Sneezing Weight change Change in thirst Change in appetite Change in urination habits None of the Above CURRENT/PREVIOUS ILLNESSES AND MEDICATIONSCURRENT DIET*SELECT ONE THAT BEST DESCRIBES YOUR PET*Indoor onlyMostly indoorsIndoor/OutdoorMostly outdoorsOutdoor onlyIS YOUR PET UP-TO-DATE ON VACCINES?* Yes No Never Vaccinated PLEASE LIST ANY HISTORY OF TRAVEL OR PREVIOUS RESIDENCE OUTSIDE OF ARIZONALAST VACCINATION DATE Month Day Year CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 485
