Home
CT Referral Form
IM Referral Form
CT Facility Rental
Contact
Home
CT Referral Form
IM Referral Form
CT Facility Rental
Contact
Intake Form
Please complete the form below
Patient's Name
*
寵物姓名
First Name
Last Name
Client Phone Number
*
登記電話
Purpose of Today's Visit
到訪目的
Is your pet Diabetic?
寵物患有糖尿病嗎?
Yes 是
No 否
What medications is your pet receiving? Include dosages if possible.
寵物正在服用的藥物(請盡量註明劑量
How has your pet's appetite been?
閣下的寵物最近的胃口如何?
increased 增加
decreased 減少
normal 正常
How has your pet's water intake been?
閣下的寵物最近的飲水量?
increased 增加
decreased 減少
normal 正常
How has your pet's energy level been?
閣下的寵物最近的活動量?
normal 正常
abnormal 出現異常
if abnormal, please explain
如出現異常，請加以描述
Has your pet had any vomiting or diarrhea since his/her last visit?
閣下的寵物上次看診後有出現嘔吐或腹瀉嗎?
Yes 有
No 沒有
If yes, then please explain
如有，請加以描述
Do you have any other concerns about your pet’s health today?
閣下今天對寵物的健康狀況有其他關注的地方嗎?
Do you need any refills of medications? If yes, please list below.
閣下需要為寵物補充藥物嗎?如有，請詳細列出。
How to contact you with results (if necessary) – email preferred
請提供如何就結果與閣下聯繫的方式 (視乎需要)
(For Drop Offs) Is there a particular time that you need to pick your pet up today?
寵物暫托服務)閣下今天需要在特定的時間接回寵物嗎?
May we share your pets story and image on our social media and in our educational materials?
*
Yes
Yes, but please do not identify my pet's name.
No
Thank you for completing the intake form. Our staff will be back with you shortly.
