Oncology Registration Form – Frederick

Welcome to Partner Veterinary Oncology! 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

Mobile Phone

Email *

Alternate Contact

Contact Name

First

Last

Home Phone

Mobile Phone

Pet Details

Pet's Name *

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

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

Other medical problems (ongoing care only): *

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:

Has your pet had any prior surgeries? *

• Yes
• No

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

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

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

Current appetite level: *NormalDecreasedIncreased

Current water intake: *NormalDecreasedIncreased

Urinary behaviors: *NormalDecreasedIncreased

Current diet:

Current activity level: *NormalDecreasedIncreased

Any vomiting or diarrhea? *

• Yes
• No

If yes, please describe:

Any coughing, sneezing, or nasal discharge? *

• Yes
• No

If yes, please describe:

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

• Yes
• No

Please state if positive or negative for each:

Consent for use of CoVet AI:

Checkboxes *

• 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.

Checkboxes (copy) *

• 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 care

How did you find out about us? *

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

Which event did you attend?

Please let us know how you heard about us!

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