Houston TeleVet Intake Form

First Name

Last Name

Phone Number

What species is your pet?

Dog Cat

How old is your pet?

How much does your pet weigh?

Is your pet male or female?

Male Female

Is your pet spayed or neutered?

Yes No Unsure

Please explain the reason for your appointment today.

Has your pet received any treatment for this problem recently? If yes, explain.

Is your pet currently on any medications?

Does your pet have any allergies to medications? If yes, explain.

Is there any other medical problems/illness that your pet has been treated for in the past?

Please upload any test results you would like reviewed (optional):