"*" indicates required fieldsName First Last New or Returning Client* New Client Returning ClientIs the patient a new or returning patient? New Patient Returning PatientPage 2Email* Phone*Can we text this number? Yes NoAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Secondary Owner Information (if applicable)Secondary Owner Name First Last Secondary Phone NumberSecondary Email Continued onHow did you hear about us? Social Media Google Ad Word of Mouth OtherYour pet(s) picture or video may be taken while they are with us and used for ModernVet advertisement (www.modernvetga.com) or other social media purposes (instagram, facebook, etc) Please indicate if you authorize for their pictures/videos to be posted.* I authorize I DO NOT authorizeYour pet's medical records may be requested by another provider for services including routine or urgent care, medical specialists, boarding, grooming, and adoption services.* I hereby authorize and provide for the transfer of my pet's medical records as deemed necessary by ModernVet I DO NOT authorize or provide for the transfer of my pet's medical recordsPage 3Patient Name*Species* Feline CanineSex* Female Spayed Female Male Neutered MaleBreed*Color*Age/Birthday (if known)*Please upload and previous vaccine and medical records Drop files here or Select filesMax. file size: 256 MB.Do you have pet insurance? Yes NoName of Insurance ProviderFear, Anxiety, and Stress (FAS)Does your pet show any reluctance to getting in the car or carrier? Yes NoDoes your pet of any of the following during travel? (select any that apply) Pant Tremble Pace Hide Drool Vomit Poop Pee None of the AboveAre there any situations that your pet has tried to avoid or seemed to dislike of in the past? (select all that apply) Entering the vet hospital Unfamiliar people or animals Being put up on the exam table Going into the exam room Having a rectal temperature taken Ear Exam Nail trim None of the above OtherHas your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associates with the visit? Yes NoPage 4Do you have another pet you would like to add to your account? Yes NoPage 5Patient Name*Species* Feline CanineSex* Female Spayed Female Male Neutered MaleBreed*Color*Age/Birthday (if known)*Please upload and previous vaccine and medical records Drop files here or Select filesMax. file size: 256 MB.Do you have pet insurance? Yes NoFear, Anxiety, and Stress (FAS)Does your pet show any reluctance to getting in the car or carrier? Yes NoDoes your pet of any of the following during travel? (select any that apply) Pant Tremble Pace Hide Drool Vomit Poop Pee None of the AboveAre there any situations that your pet has tried to avoid or seemed to dislike of in the past? (select all that apply) Entering the vet hospital Unfamiliar people or animals Being put up on the exam table Going into the exam room Having a rectal temperature taken Ear Exam Nail trim None of the above OtherHas your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associates with the visit? Yes NoPage 6Do you have another pet you would like to add to your account? Yes NoPage 7Patient Name*Species* Feline CanineSex* Female Spayed Female Male Neutered MaleBreed*Color*Age/Birthday (if known):*Please upload and previous vaccine and medical records Drop files here or Select filesMax. file size: 256 MB.Do you have pet insurance? Yes NoName of Insurance ProviderFear, Anxiety, and Stress (FAS)Does your pet show any reluctance to getting in the car or carrier? Yes NoDoes your pet of any of the following during travel? (select any that apply) Pant Tremble Pace Hide Drool Vomit Poop Pee None of the AboveAre there any situations that your pet has tried to avoid or seemed to dislike of in the past? (select all that apply) Entering the vet hospital Unfamiliar people or animals Being put up on the exam table Going into the exam room Having a rectal temperature taken Ear Exam Nail trim None of the above OtherHas your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associates with the visit? Yes NoPage 9Patient being seen*Species* Canine FelineSick/Injured or Wellness* Sick/Injured WellnessPage 10WellnessReason for visit*Check any that apply* Coughing Sneezing Vomiting Diarrhea Itchy skin, paws, etc NoneIf having any of the previous symptoms, how long and how often is symptom occurring*If having any of the previous symptoms, how long and how often is symptom occurringIs he/she eating and drinking well?* Yes NoPlease list the brand of food that you are currently feedingHow often are you feeding? Once daily Twice daily Three times daily Four times dailyHow much are you feeding per meal?Environment Indoor Outdoor Outdoor only with SupervisionEnvironment Boarding Grooming Hiking Swimming (Lakes, pools, beach, etc) NoneIs he/she currently on any medications or preventatives?* Yes NoPlease list any medication and/or preventatives that your pet is on and when last given:Does your pet have any major medical history that we need to be aware of?* Yes NoIf so, please describe below:Senior Pet (over seven years)Have you noticed any changes in your pet's personality or activity level? Less or more active Slow to rise after resting or sitting Urine or stool accidents in the house Disoriented at times or failure to recognize familiar people Limping after exercise Lagging behind on walks Difficulty jumping or with stairs Feeling stiffIs your pet having trouble with activities such as climbing stairs or jumping? Yes NoHave you noticed any significant, unplanned, weight changes with your pet in recent months? Yes NoPage 11Sick/InjuredPlease select all that apply* Coughing and/or sneezing Vomiting and/or diarrhea Eye or ear issues Excessive licking, chewing, biting of the skin, paws, butt, etc Straining to defecate Straining to urinate Increased water intake/ Increased urination Lethargy Mobility issues Weight loss Not eating/ decreased appetite Injured paw or broken nail OtherPlease explain your pets illness in detail as well as the duration, how often, any recent changes (food, environment, etc) or any important information that would be helpful to us below:*Environment Indoor Outdoor Outdoor only with SupervisionEnvironment Boarding Grooming Hiking Swimming (Lakes, pools, beach, etc) NoneIs your pet on any flea, tick and heartworm preventatives?* Yes NoName of preventative medicationWhat date were preventatives last given? MM slash DD slash YYYY Is your pet currently on any medications?* Yes NoPlease list any medications your pet is currently taking, including dosage and how often given:Page 12Do you have another pet that is being seen? Yes NoPatient name*Species* Canine FelineSick/Injured or Wellness?* Sick/Injured WellnessPage 13WellnessReason for visit*Check any that apply* Coughing Sneezing Vomiting Diarrhea Itchy skin, paws, etc NoneIf having any of the previous symptoms, how long and how often is symptom occurring*Is he/she eating and drinking well?* Yes NoPlease list the brand of food that you are currently feedingHow often are you feeding? Once daily Twice daily Three times daily Four times dailyHow much are you feeding per meal?Environment Indoor Outdoor Outdoor only with SupervisionEnvironment Boarding Grooming Hiking Swimming (Lakes, pools, beach, etc) NoneIs he/she currently on any medications or preventatives?* Yes NoPlease list any medication and/or preventatives that your pet is on and when last given:Does your pet have any major medical history that we need to be aware of? Yes NoIf so, please describe belowSenior Pet (over seven years)Have you noticed any changes in your pet's personality or activity level? Less or more active Slow to rise after resting or sitting Urine or stool accidents in the house Disoriented at times or failure to recognize familiar people Limping after exercise Lagging behind on walks Difficulty jumping or with stairs Feeling stiffIs your pet having trouble with activities such as climbing stairs or jumping? Yes NoHave you noticed any significant, unplanned, weight changes with your pet in recent months? Yes NoPage 14Sick/InjuredPlease select all that apply* Coughing and/or sneezing Vomiting and/or diarrhea Eye or ear issues Excessive licking, chewing, biting of the skin, paws, butt, etc Straining to defecate Straining to urinate Increased water intake/ Increased urination Lethargy Mobility issues Weight loss Not eating/ decreased appetite Injured paw or broken nail OtherPlease explain your pets illness in detail as well as the duration, how often, any recent changes (food, environment, etc) or any important information that would be helpful to us below:*Environment Boarding Grooming Hiking Swimming (Lakes, pools, beach, etc) NoneIs your pet on any flea, tick and heartworm preventatives? Yes NoName of preventative medicationWhat date were preventatives last given? MM slash DD slash YYYY Is your pet currently on any medications?* Yes NoPlease list any medications your pet is currently taking, including dosage and how often given: Are you passionate about making a difference in the lives of animals?If so, we want to hear from you!REACH OUT TODAY
