Appointment History Questionnaire Appointment History Questionnaire Please complete this form to the best of your ability to save time during your appointment. Thank you! Client Information Your name * Required Please include First and Last Name Email * Required Phone * Required Do you already have an appointment scheduled for your pet? * Required Yes No Please call us to schedule your appointment (616-531-7387). This form is for pre-appointment history and concerns only, not appointment requests. We look forward to your call! When is your pet’s appointment? * Required Are you the person bringing your pet to the appointment? * Required Yes No Please provide the name and phone number of the person who will be at the appointment: Name * Required Phone * Required Is this person authorized to make financial or medical decisions for you or your pet? * Required Yes No Patient Information Pet’s Name * Required If you are bringing more than one pet, please fill out one form for each pet. Has this pet been seen at Animal Medical Center before? * Required Yes No Species * Required Dog Cat Exotic/OtherExotic/Other Breed * Required Date of Birth/Age * Required Enter unknown if not sure Do you have pet insurance? * Required Yes No What is the name of your pet insurance provider? Previous Medical History Do you have previous veterinary records, adoption paperwork, breeder paperwork, etc.? * Required Yes No Upload History Drop a file here or click to upload. Choose File Maximum file size: 10MB Please upload previous medical history, vaccination records, adoption paperwork, etc. You can upload multiple files if needed. If you are unable to upload, please skip and bring all paperwork/history to your appointment. Is there a previous veterinary hospital we can contact for a copy of medical records? * Required Yes No Please provide us with as much information as possible about your pet’s previous veterinarian so we may contact them for previous medical history. Previous Veterinary Hospital Previous Veterinary Hospital * Required City, State Phone Website/URL Pet/Owner name on file Please provide the owner and/or pet name on file if different than what you provided above. If you are human, leave this field blank. Next
