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503-655-1722 22320 Salamo RoadWest Linn,
OR 97068

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22320 Salamo Rd,
West Linn, OR 97068

Call / Text: 503-655-1722

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Home » Online Patient History Form

Online Patient History Form

Pet Name:*
Client Name*
First Last
Decision Makers Name*
Decision Makers Phone*
Email*
Does your pet have insurance?*
- Yes
- No
If "Yes" above please let us know which Insurance Company
Do you have time constraints?*
For today's visit the following symptoms are present:
- No symptoms present
- Coughing
- Sneezing
- Vomiting
- Diarrhea
- Lethargy
- Lameness
- Itching
- Lumps/Bumps
- Other Symptoms/Concerns (list):
Other Symptoms/Concerns (list):*
Monthly heartworm / deworming / flea preventive:*
- None
- Trifexis
- Interceptor Plus
- Heartgard
- Nexgard
- Bravecto
- Revolution
- Cheristin
- Vectra
- Frontline
- Advantage
Current medications/supplements and dose given:*
Current diet:*
Any recent changes to the diet?*
- Yes
- No
Please explain diet changes:
Appetite:*
- Normal
- Decreased
- Increased
Any change in food/treats?*
- YES
- NO
Water Intake*
- Normal
- Decreased
- Increased
Activity Level*
- Normal
- Abnormal
Food Allergies?*
Other Allergies?*
Any seizures?*
Percentage of time spent indoors:*
HISTORY
How is your pet doing at home?*
Have you noticed any changes to their normal behavior?*
- YES
- NO
What concerns that you would like to address today?*
Do you need any medication refills?*
- YES
- NO
Other
Entering Your Full Name Here Will Serve As Your Digital Signature:*
Date*
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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Cascade Summit Animal Hospital © 2020
22320 Salamo Road, West Linn OR 97068

Call or Text 503-655-1722

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Monday – Friday:
8:00am – 6:00pm

Saturday – Sunday:
Closed