Patient History Form in Fargo, ND | Southgate Veterinary Hospital

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Other Medical History

If your pet has medical history from another veterinary facility, please have them email us the records to yourpetsvet@sgvet.com

Pet's Name*

First Last

Your Name*

First Last

It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

Where can we call you at while your pet is here?*

Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?

Yes
No

Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?*

Yes
No

Reason for your pet's visit today?*

This issue began on*

This issue is:*

Has your pet had any:

Other*

My pet's appetite is:*

My pet's thirst level is:*

My pet's activity level is:*

My pet's urination is:*

My pet eats*

Brand of Pet Food*

If prescription diet, what formulation?

How Often Is Your Pet Fed?*

How Much Is Your Pet Fed PER MEAL?*

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)

Has your pet's diet changed in the last 6 months?

Yes
No
I am not sure

Is it possible for your pet to have

Eaten garbage
Ingested toxins (rat bait, ant bait, other known toxic substances)
Ingested Mushrooms
Ingested Marijuana
Eaten toys (part of toys missing, chewed up etc.)
Eaten grain free diet for any period of time
Ingested human or animal medications not intended for them or at higher doses than intended?
NONE OF THE ABOVE ARE POSSIBLE

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:

When Was Your Pet's Last Dose of Heartworm Preventative?*

Date Given (Please type N/A if not on a preventative)

What Kind of Heartworm Preventative Do You Use?*

Name of medication - put unknown if not sure

When Was Your Pet's Last Dose of Flea/Tick Preventative?*

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use?*

Name of medication - put unknown if not sure

Is Your Pet

Are There Other Pet's In The Home

Yes
No

Does Your Pet

Is Your Pet Current On Vaccinations?*

Yes
No
I Am Not Sure

My pet's vaccines were administered last by:

At Southgate Veterinary Hosp
I Am Not Sure Where

Does Your Pet Have A Microchip?

Yes
No
I am not sure

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?

If yes, please tell us more. If no, please note N/A

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

Is There Anything Else You Would Like To Discuss Today?

Appointment Procedures

I understand the COVID-19 precautions: If I am sick, have been exposed, or have a pending test: I will reschedule my appointment or find someone whom can transport my pet.*

Initial

I understand that payment is due in full at the time services are rendered. This includes services authorized by another responsible party listed on my account; and/or by phone.*

Initial

Signature*