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About
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About
Services
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Careers
Book Appointment

Online Forms

Existing Client Information Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

A veterinarian examines a dog using a stethoscope during a routine check-up

Client's Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Emergency/Alternate Phone(Required)

Spouse/Partner(Required)

First Last

Spouse/Partner Phone(Required)

Pet #1 Name(Required)

First

Pet #1 Species(Required)

Pet #1 Breed(Required)

Pet #1 Sex(Required)

Male

Male - Neutered

Female

Female - Spayed

Pet #1 Color(Required)

Pet #1 Age/Birthday(Required)

Is your pet on any medications?(Required)

Yes

No

Medication Name

How much medication are they given?

How often is the medication given?

Date of last dose given?

Brand of food given?(Required)

How many times per day are they fed?(Required)

One

Two

Three

Four

And, how much are they fed at each feeding?(Required)

1/2 Cup

3/4 Cup

1 Cup

2 Cups

More than 2 Cups

How many times a day do you feed them?(Required)

What heartworm preventative do you give your pet?(Required)

When was the last dose given?(Required)

Do you have another pet to add?

Yes

No

Pet #2 Name

First

Pet #2 Species

Pet #2 Breed

Pet #2 Sex

Male

Male - Neutered

Female

Female - Spayed

Pet #2 Color

Pet #2 Age/Birthday

Is your pet on any medications?

Yes

No

Medication Name

How much medication are they given?

How often is the medication given?

Date of last dose given?

Brand of food given?

How many times per day are they fed?

One

Two

Three

Four

And, how much are they fed at each feeding?

1/2 Cup

3/4 Cup

1 Cup

2 Cups

More than 2 Cups

How many times a day do you feed them?

What heartworm preventative do you give your pet?

When was the last dose given?

Do you have another pet to add?

Yes

No

Pet #3 Name

First

Pet #3 Species

Pet #3 Breed

Pet #3 Sex

Male

Male - Neutered

Female

Female - Spayed

Pet #3 Color

Pet #3 Age/Birthday

Is your pet on any medications?

Yes

No

Medication Name

How much medication are they given?

How often is the medication given?

How often is the medication given?

Brand of food given?

How many times per day are they fed?

One

Two

Three

Four

And, how much are they fed at each feeding?

1/2 Cup

3/4 Cup

1 Cup

2 Cups

More than 2 Cups

How many times a day do you feed them?

What heartworm preventative do you give your pet?

When was the last dose given?

Do you have another pet to add?

Yes

No

Pet #4 Name

First

Pet #4 Species

Pet #4 Breed

Pet #4 Sex

Male

Male - Neutered

Female

Female - Spayed

Pet #4 Color

Pet #4 Age/Birthday

Is your pet on any medications?

Yes

No

Medication Name

How much medication are they given?

Date of last dose given?

Brand of food given?

How many times per day are they fed?

One

Two

Three

Four

And, how much are they fed at each feeding?

1/2 Cup

3/4 Cup

1 Cup

2 Cups

More than 2 Cups

How many times a day do you feed them?

What heartworm preventative do you give your pet?

When was the last dose given?

Which pet(s) is this appointment for?

Please select any canine vaccines your pet will be needing:

Rabies

DHPP

DHLPP

Influenza

Rattlesnake

Bordetella

Please select any feline vaccines your pet will be needing:

Rabies

FVRCP-C

Feline Leukemia

Diagnostics needed:

Heartworm Test

Annual Bloodwork

Bloodwork to refill Prescription

Fecal

Urinalysis

Nail Trim

Anal Gland Expression

Any other services needed?

Please indicate any medical concerns or changes in behaviors you’ve noticed since their last exam.

Arthritis

Blindness

Deaf

Chewing/Licking at feet

Walks in Circles

Constipation

Coughing

Sneezing

Hacking

Diarrhea

Cloudy Discharge from Eyes

Gagging

Not Urinating

Head Tilt

Lethargic

Licking/Chewing at Skin

Nasal Discharge

Seizures

Frequent Urination

Wounds

Increase/Decrease in Appetite

New Lumps/Bumps/Masses

Thunderstorm Anxiety

Incontinence

Limping

Weight Gain/Loss

Increased water intake

Vomiting

Fearful

Increase in size of

What other concerns or issues do you want to make sure the Doctor addresses, examines or discusses with you during the exam?

What prescription refills will your pet need during their visit?

Heartworm

Flea & Tick

Insulin

Anxiety Medication

Prescription Diet Food

Other

If Other, please list what you need.

Is this a new pet for your family?

Yes

No

If so, please indicate how long you’ve had them.

And, where did you get them?

Rescue

Shelter

Stray

Breeder

Other

If Other, please explain.

What kind of treats, snacks, table scraps and/or chews do you give your pet?

Does your pet have any sensitivities (activities, situations, or areas on the body)?

Yes

No

If so, please indicate what they are or what the triggers are:

Has your pet ever bitten anyone or other dogs?

Yes

No

Has your pet ever shown anxieties when visiting the Veterinarian?

Yes

No

Please indicate if your pet will be exposed to any of the following:

Doggie Daycare

Boarding

Grooming

Training

Local Dog Park

Walks around Neighborhood

Pet-Friendly Stores/Malls

Walks in the Woods/Trails

Swimming in Neighborhood Lake/Creek/Pool

Wooded Backyard

Other

If Other, please explain.

Will your pet primarily be inside or outside?

Yes

No

How much of their time will be spent outdoors? (Please indicate time spent outside, i.e. two hours, most of the day, just for potty breaks)

Indicate the activity level that best suits your pet:

Very relaxed

Moderate

High Energy

What dental care do you provide your pet at home:

Brush teeth

Oral rinse/gel

Dental Diet

CET Hextra Chews

Greenies

Purina Dental Chews

Drinking water additive

None

Other

If Other, please explain.

Has your pet been seen by another Veterinarian or been to the Emergency Hospital since your last visit?

Yes

No

If Yes, please explain.

READY FOR A VISIT?

Existing clients can book online! Just use the Book An Appointment button. If you are a new client, please call us to schedule your pet’s appointment. We look forward to seeing you soon!

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Get in touch

Get in touch with our team! Complete the form below, and a member of our team will be in touch with you shortly. If you’re in need of immediate assistance, please call us directly at 432-694-2537.

Address

3537 Andrews Hwy
Midland, TX 79703

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Hours

Mon – Fri: 8:30 am – 12:00 pm;
1:30 pm – 6:00 pm
Sat & Sun: Closed

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Contact

Phone: 432-694-2537
Email: info@animalclinicandhospital.com

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