Client Information

Your Name*

First Last

Pet's name*

Best cell # to reach you at*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Please ensure that you are avaible at one of the above numbers during your pet’s appointment

For New Clients

To save time, please have your previous veterinarian send your pet’s records to info@bellvethospital.com.

Name of Previous Hospital

Previous Hospital Phone

Patient History

Species*

Canine
Feline

Your pet’s current problem(s)*

Duration and frequency of problem(s)*

Is the problem*

the same
better
worse
N/A

Has a similar problem happened in the past?*

Yes
No
N/A

How is your pet's appetite?*

the same
increased
decreased

What is your pet's current diet?*

Please include type/brand, frequency, time of day and any regular treats given.

Please list any medications & supplements

Please include type/brand, dosage, frequency and time of day given.

Do you need a refill of this medication today?*

Yes
No
N/A

Your pet's travel history (last 5 years):*

Please include both national and international travel.

Does your DOG have access to dog parks, hiking, camping, etc?*

Yes
No
N/A

Does your CAT have access to outdoors or other outdoor cats?*

Indoor Only
Outdoor Exposure
N/A

Is your pet coughing?*

Yes
No

Comments

Is your pet sneezing?*

Yes
No

Comments

Has your pet lost weight?*

Yes
No

Comments

Does your pet have increased drinking/urination?*

Yes
No

Comments

Is your pet vomiting?*

Yes
No

Comments

Does your pet have diarrhea?*

Yes
No

Comments

Does your pet have a microchip*

Yes
No
I don’t know

Is your pet on parasite control?*

Yes
No

What brand/type/frequency?

Do you need a refill of this prescription today?*

NO
Yes, 6 months refill
Yes, 12 months refill

If your pet is due for vaccines today, would you like us to:*

Proceed with updating vaccines
Discuss with the veterinarian first before vaccinating

Authorizations

Diagnostic and Treatment Authorizations (please select one):*

Please call me with an estimate before any diagnostics or treatments are performed.
I do not need an estimate and authorize all recommended diagnostics and treatments.

Client Full Name:*

CAPTCHA

Address:	26318 State Highway 129 Haleyville, AL 35565
Phone:	205-486-4500
E-mail:	info@bellvethospital.com

Patient Intake Form

You may complete the web form and submit it online below or click the button to download the form and submit via email, ahead of your pet’s appointment.

How to download and email the PDF form:

Online Patient Intake Form

Client Information

For New Clients

Patient History

Authorizations

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