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22320 Salamo Rd,
West Linn, OR 97068

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Services
Holistic Care
About
Resources
Contact
Emergency

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):*
Current diet: (what brand of food and amount fed per day. i.e. 2 cups twice daily, 1/4 can three times daily)*
Any recent changes to the diet?*
- Yes
- No
Please explain diet changes:
Any change in food/treats?*
- YES
- NO
Current medications/supplements and dose given:*
Monthly heartworm / deworming / flea preventive:*
- None
- Trifexis
- Interceptor Plus
- Heartgard
- Nexgard
- Bravecto
- Revolution
- Cheristin
- Vectra
- Frontline
- Advantage
- Simparica Trio
Appetite:*
- Normal
- Decreased
- Increased
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
Owner's Signature*
Date*
Month
Day
Year
Help us fight SPAM! Please tell us what TWO plus 3 equals?*
The SUBMIT button will appear when the question is answered correctly.
Comments
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Cascade Summit Animal Hospital

22320 Salamo Rd
West Linn, OR 97068

Cascade Summit Animal Hospital is a full service animal hospital, providing medical, dental, diagnostic, surgical and holistic services

https://cascadesummitvets.com/

Hospital Hours

Monday	8:00 am - 6:00pm
Tuesday	8:00 am - 6:00pm
Wednesday	8:00 am - 6:00pm
Thursday	8:00 am - 6:00pm
Friday	8:00 am - 6:00pm
Weekend	CLOSED

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