Name *

First

Last

Who else is authorized to make decisions about your pet's healthcare?

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please let us know where we should park or if there are specific instructions for us once we arrive at your address.

Primary Phone *

Secondary Phone

Place of Employment

Email *

How did you hear about us? *

Social Media
Our Website/Internet Search
Client
Business Card/Flier/Advertisement

Name of Previous Veterinary Clinic/Hospital *

When was your pet last examined by a veterinarian? *

Is your pet up to date vaccines? *

Yes
No

Your pet must be up to date on his or her rabies vaccination. If you are unable to provide proof of a current/valid rabies vaccination we can administer a rabies vaccine and provide a Rabies Certificate.

Is your pet up to date on flea/tick/heartworm preventative medications? *

Yes
No

Pet's Name *

Pet's Date Of Birth *

Species (dog or cat) *

Breed *

Color *

Sex and Reproductive Status *

Intact Male
Neutered Male
Female
Spayed Female

My pet is *

Indoor Only
Outdoor Only
Mix of Indoor and Outdoor

My pet's approximate weight in pounds:

Please tell us about any serious illness and/or surgeries *

ex: Hospitalized in 2010 for pancreatitis at XYZ Emergency Hospital; Diagnosed with Feline Asthma in 2020 at XYZ Animal Clinic

Any allergies to vaccinations, food, or medications? *

If your pet has had a documented vaccine reaction in the past we will not be able to vaccinate them. Instead, we will refer you to a full service veterinary clinic/hospital.

Does your pet take any medications or eat a Prescription diet? *

Example: Medication -> Apoquel 16 mg once daily since 2017. Example: Prescription Diet -> 2 cups of Royal Canine Satiety Support twice daily.

Will your pet need refills of any medications? If so, please upload photos of the medications. Please ensure that medication instructions are visible.

Click or drag files to this area to upload. You can upload up to 5 files.

Updated lab work may be required before refilling certain medications. If you can't take photos please include the names of the medications in the box above this one.

Today my pet is being evaluated for one of the following: *

Annual Exam (yearly exam, blood work, vaccines, etc.)
Minor Illness (skin infection, ear infection, broken toenail, limping, etc.)

Any other information you'd like to add as it pertains to this visit? *

If you schedule an annual exam, Dr. Cover will assess a maximum of two additional health concerns before the appointment is converted to an urgent illness exam. Please review our website for current pricing of an urgent illness exam as this is different from the price for an annual exam. *If you have refill request you may list them here*

Are you able to safely handle (i.e hold, restrain etc) your pet so that Dr. Cover can perform basic Veterinary Services? If you are not comfortable handling your pet please let Dr. Cover know. *

Basic Veterinary Services include, but are not limited to, blood draw, injections, etc.

Is your pet fearful, aggressive, anxious, etc? Please let us know if your pet has ever bitten another animal or a human. *

If you are not able to safely handle your pet then we may employ additional handling methods (i.e. muzzle, additional veterinary assistance etc). Please review the policy agreement for more information.

We frequently use peanut butter and canned cheese as treats during examinations - are there any allergies within your home that would mean we need to examine your pets without these food items? *

Yes
No

Consent given for images and/or video of you and/or your pet(s) to be used on our website, social media pages, or promotional materials? *

Yes
No

Please upload your pet's previous medical records.

Click or drag files to this area to upload. You can upload up to 5 files.

If you are unable to upload them during this session we ask that you email them to info@aysmobilevet.com at least 48 hours prior to your appointment. If we do not receive the medical records - your appointment may be cancelled.

Today's Date *

Please check the following *

I have read and agree to The Policy Agreement

Online Forms

New Client Form

New Client Form

Get Started

Request an Appointment

Hours

Contact Information

Phone

Email

Contact Us

We’re Here to Help