IMED Registration Form – Frederick Welcome to Partner Veterinary Internal Medicine! Thank you for giving us the opportunity to care for your beloved pet. Click here for a PDF version of this form. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client Details Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Mobile PhoneWork PhoneMay we contact you at work? YesNoCommunication preference: *CallEmailTextAlternate Contact Contact Name FirstLastMobile PhoneEmailPet Details Pet's Name *Microchip No.:Species *DogCatGender *MaleFemaleBreed *Spayed/neutered? *YesNoColor/markings:If yes, at what age?Does your pet have any known stressors or behavioral triggers during veterinary visits? (e.g., fear of loud noises, reactivity to other dogs, sensitive to being touched in certain areas) *Was your pet adopted or purchased from a breeder? *AdoptedPurchased from a breederInitial Visit Questionnaire Primary Veterinary Office and any other hospitals seen in the last 2 years *Diagnosis (if known) & Date of Diagnosis: *When was the problem first noticed? *Compare your pet's condition now to when the problem first started (size change for masses/lymph nodes, pain level, etc.): *Other medical problems (ongoing care only): *Has your pet had any prior surgeries? *YesNoIf 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) *YesNoAny known allergies (food, medication, other)? *Current appetite level: *NormalDecreasedIncreasedCurrent diet (including brand of food, quantity, and frequency fed) as well as any significant previous dietary history Current activity level: *NormalDecreasedIncreasedIs your pet experiencing any of the following (& describe): Any vomiting or diarrhea? *YesNoAny coughing, sneezing, or nasal discharge? *YesNoIf yes, please describe:If yes, please describe:Is your pet currently on heartworm, flea, and tick preventatives? YesNoCurrent medications (include name, dose, route, and frequency): *For cats only: has your pet been tested for feline leukemia and/or FIV? Please state if positive or negative for each: Client Acknowledgements & Permissions 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. If an anesthetic procedure is warranted, we will schedule this at a different time. *I acknowledgePlease 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 acknowledgeConsent for use of CoVet AI: *I understand that this hospital utilizes CoVet AI, an artificial intelligence–based support tool, to assist veterinary staff with medical documentation, visit summaries, discharge instructions, and internal workflow processes. AI-assisted audio recording may be used in exam rooms and during phone calls for medical transcription. I acknowledge that CoVet AI does not replace professional veterinary judgment and that all diagnoses, medical decisions, and treatment recommendations are made solely by a licensed veterinarian. *I acknowledge that this practice uses CoVet AI technology to assist with medical documentation and certain communications between veterinarians, staff, and clients. This technology is used to help summarize conversations, improve the accuracy of medical records, and enhance administrative efficiency so that veterinarians may devote more time to patient careDo we have your permission to share pictures and stories of your pet on social media? *YesNoHow did you hear about Partner? *My Primary Care VeterinarianSocial MediaGoogleFriend/Family RecommendationRadio AdEventOtherPrimary Care Veterinarian/HospitalWhich event did you attend?Please let us know how you heard about us!Submit
