IMED Registration Form – Frederick

Welcome to Partner Veterinary Internal Medicine! Thank you for giving us the opportunity to care for your beloved pet.

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Client Details

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

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Zip Code

Home Phone

Work Phone

Mobile Phone

May we contact you at work? YesNo

Communication preference: *

• Call
• Email
• Text

Email *

Alternate Contact

Contact Name

First

Last

Home Phone

Work Phone

Mobile Phone

May we contact you at work?YesNo

Pet Details

Pet's Name *

Microchip No.:

Species *

• Dog
• Cat

Gender *

• Male
• Female

Spayed/neutered? *

• Yes
• No

Breed *

Color/markings:

Behavior Warning: *

Primary Veterinary Office *

Initial Visit Questionnaire

Diagnosis and Date of Diagnosis *

When did the problem first start? *

Compare your pet's condition now to when the problem first started (size change for masses/lymph nodes, pain level, etc.): *

At what age was your pet spayed/neutered? *

Has your pet ever been bred? *

• Yes
• No

Was your pet adopted or purchased from a breeder? *

• Adopted
• Purchased from a breeder

If your pet was purchased, is breeder information available?

• Yes
• No

Does your family own any pets from the same breeder/bloodline (siblings, other)? *

• Yes
• No

Other medical problems (ongoing care only): *

Has your pet had any prior surgeries? *

• Yes
• No

If so, please list procedure(s) and date(s) when performed:

Does your pet have a previous history of cancer? (If yes, please list past diagnoses and dates) *

• Yes
• No

If yes, please list past diagnoses and dates:

Current medications (include name, dose, route, and frequency): *

Any known allergies (food, medication, other)? *

Current appetite level: *NormalDecreasedIncreased

Current activity level: *NormalDecreasedIncreased

Current diet:

Any vomiting or diarrhea? *

• Yes
• No

If yes, please describe:

Any coughing, sneezing, or nasal discharge? *

• Yes
• No

If yes, please describe:

Any neurologic symptoms (ataxia, seizures, etc.)? *

• Yes
• No

If yes, please describe:

For dogs only: What is your pet's heartworm status and is he/she currently on prevention?

• Yes
• No

If yes, please state which preventive:

For cats only: Has your pet been tested for feline leukemia and/or FIV?

• Yes
• No

please state if positive or negative for each:

Please be advised that we are happy to interpret future bloodwork/testing from your primary care veterinarian; however, a diagnostic consultation fee will apply. This fee will vary depending on which lab panel is recommended and it accounts for the time spent interpreting the test results, formulating a plan, and communicating that plan to any parties involved. By checking this box, I acknowledge that there will be an additional charge for this service. *

• I acknowledge

Do we have your permission to share pictures and stories of your pet on social media? *

• Yes
• No

How did you hear about Partner? *

• My Primary Care Veterinarian
• Social Media
• Google
• Friend/Family Recommendation
• Radio Ad
• Event
• Other

Primary Care Veterinarian/Hospital

Which event did you attend?

Please let us know how you heard about us!

Opt-In/Opt-Out for Text Messaging Services

Please indicate your preference below: *

• Yes, I consent to receive SMS text messages from Partner Veterinary Emergency & Specialty Center.
• No, I do not consent to receive email and/or SMS text messages from Partner Veterinary Emergency & Specialty Center.

By selecting “Yes”, you consent to receive SMS text messages from us. Message frequency may vary. Not all carriers are supported. Standard message and data rates may apply. You may update your preferences or withdraw your consent at any time by notifying us or by replying CANCEL or STOP to any message you receive.

If your pet has been prescribed any anti-anxiety medication (such as Trazodone or Gabapentin), please ensure that you give it at least 2 hours before the IMED consult.

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