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 *

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

• Yes
• No

How did you find out about us?

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

If your pet was purchased, is breeder information available? *

• Yes
• No

Was your pet adopted or purchased from a breeder? *

• 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:

*

• By checking this box, I acknowledge that there will be an additional charge if any IMED-recommended lab work is done at my primary veterinarian, and that this cost will vary depending on which lab panel is ordered.

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!

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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