Patient Intake Form

Name(Required)

First

Last

Patient's name(Required)

Email(Required)

[email protected]

I understand that dropping off my pet does not guarantee a Veterinarian will examine my pet today.(Required)

Initial here

Appointment date(Required)

Best Phone number to reach you(Required)

Is this a wellness and vaccine appointment?(Required)

Yes

Yes, but I have additional concerns

Today's presenting concern (please be specific) and when did the symptoms start?(Required)

Please list the frequency and dosage of all medications or supplements your pet is taking (if any)(Required)

Has your pet been vomiting, had diarrhea, coughing or sneezing (if yes, please describe)(Required)

If your pet eating and drinking normally? Any recent change in diet?(Required)

By dropping your pet off for care at Bemidji Veterinary Hospital, you authorize the doctor to treat as deemed necessary. If there is a monetary limit you do not want to exceed, please specify:(Required)

I would like an estimate prior to treatment following my pet's exam:(Required)

Yes

No, please proceed with treatment as needed

If the doctor feels lab work such as a blood panel or x-rays are appropriate in your pet's care, do you authorize such tests?(Required)

Yes

No, do not proceed until we discuss further-I will be available to contact

CAPTCHA

What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care

Payment Options