Intake Form Pet Parent Information * First Name Last Name Email * Primary Phone * (###) ### #### Alternate Phone (###) ### #### Pet's Name * Reason for consultation * Have you noticed (click all that apply): Increased Appetite Decreased Appetite Increased Drinking Vomiting Diarrhea Difficulty Defecating Increased Urination Difficulty Urinating Weight Loss Coughing List current medications and supplements: Does your pet require a medication refill? Share Media UPLOAD If you have a photo or video depicting your pet's problem, then please share it with us. Do you have Pet Insurance? Consent * There are limitations of telemedicine, including the inability to perform a hands-on physical examination of my pet, potentially leading to challenges in diagnosis. I understand and acknowledge the limitations Authorization * The information provided is accurate to the best of my knowledge. I hereby authorize My Animal Veterinary Clinic to provide veterinary care for my pet from this date forward. I understand that I am responsible for all charges incurred for the care of my pet(s) and that payment for the telemedicine service is due upon submission of this form. Check box to certify by electronic signature Authorized Electronic Signature * Date * MM DD YYYY Thank you - we look forward to your appointment.
