Urgent Care Patient History Sheet – Safe Haven Veterinary

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Integrative Medicine: Wed & Thurs 8am to 5pm
Urgent Care: Mon - Fri 8am to 6pm
Internal Medicine: Tues, Wed & Fri 8am to 5pm
(724) 591-8393

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For Pet Owners
For Veterinarians
- Referrals
  - Internal Medicine Patient Referral Form
  - Urgent Care Patient Referral Form
Contact Us

Menu

About Us
Services
For Pet Owners
For Veterinarians
- Referrals
  - Internal Medicine Patient Referral Form
  - Urgent Care Patient Referral Form
Contact Us

At Safe Haven Veterinary Hospital, our mission is clear: Your Pet is Our Pet.

Click here for a PDF version

URGENT CARE PATIENT SHEET

Patient Name:(Required)

First Last

Your Name:(Required)

First Last

Email(Required)

Today's Date:(Required)

MM slash DD slash YYYY

If feline:

Indoor

Outdoor

Indoor & Outdoor

What are your concerns about your pet?(Required)

Please list any additional household pets:(Required)

Pet's current diet:(Required)

When was your pet last vaccinated?(Required)

Have you traveled with your pet recently? If so, where?(Required)

List any flea/tick/heartworm preventative:(Required)

Please outline additional medical history, including surgeries, allergies, and special needs:(Required)

Current Medications:

Medication:

Dosage/Frequency:

Pet's Response:

Medication:

Dosage/Frequency:

Pet's Response:

Medication:

Dosage/Frequency:

Pet's Response:

Medication:

Dosage/Frequency:

Pet's Response:

Discontinued or Completed Medications:

Medication:

Dosage/Frequency:

Pet's Response:

Medication:

Dosage/Frequency:

Pet's Response:

Medication:

Dosage/Frequency:

Pet's Response:

Has your pet exhibited any of the following?

Lethargy:(Required)

Yes

No

If yes, duration:

Change in water consumtion:(Required)

Yes

No

If yes, duration:

If yes, increase or decrease?

Change in urination:(Required)

Yes

No

If yes, duration:

If yes, increase or decrease?

If yes, is there straining or blood?

Change in appetite:(Required)

Yes

No

If yes, duration:

If yes, increase or decrease?

If decrease, are they interested in eating?

If decrease, is there oral pain?

Vomiting:(Required)

Yes

No

If yes, duration:

If yes, active or passive?

If yes, is it food OR bile/saliva?

Diarrhea:(Required)

Yes

No

If yes, duration:

If yes, is there blood and/or mucus?

If yes, is there straining?

If yes, is there abnormal stool color? Describe if so.

If yes, is stool watery?

If yes, is there a sense of urgency?

Constipation:(Required)

Yes

No

If yes, duration:

Weight Loss:(Required)

Yes

No

If yes, over what time period?

If yes, has the pet's appetite increased, decreased, or is unchanged?

Gagging/retcheing:(Required)

Yes

No

If yes, duration:

Coughing:(Required)

Yes

No

Sneezing:(Required)

Yes

No

Abnormal breathing:(Required)

Yes

No

If yes, please describe:

If yes, is it associated with activity or excitement?

Other:

Phone

This field is for validation purposes and should be left unchanged.

Δ

(724) 591-8393

Hours:

Urgent Care: Monday - Friday, 8am to 6pm
Internal Medicine: Tuesday, Wednesday, Friday 8am to 5pm
Every Other Saturday: 8am to 2pm
Integrative Medicine: Wednesday & Thursday, 8am to 5pm

Our first Saturday opening in 2024 was on January 13th.

13085 Perry Hwy, Wexford, PA 15090