Download Printable VersionDay of your appointmentDate* MM slash DD slash YYYY Owner Name* First Last Owner's birthdate* MM slash DD slash YYYY Phone*Email* Co-Owner Name: First Last Co-Owner PhoneCo-Owner Email Street Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?* Google Facebook/Instagram Personal Recommendation If Personal Recommendation, who may we thank?*Would you prefer an in-person visit or remain curbside?* In-Person Visit CurbsidePatient InformationCat’s Name*Hair Length* Short Medium LongSex* Female Spayed Female Male Neutered MaleColor*Approximate Age/Date of Birth*Does your cat have past medical records? (If so please bring with you to appointment.)* Yes NoPatient VisitReason for Visit* Exam Exam w/ Lab Work Exam w/ Vaccines Illness or Injury Recheck BoostersOther Services: (All other services will be at an additional cost) Express Anal Glands Nail Trim Shave Matts Shave RearYour Cat’s Lifestyle* Indoor Only Indoor Mostly Outdoor Only Outdoor Mostly In and Out FreelyDo you have any concerns with your cat?* None Increased Appetite Decreased Appetite Increased Drinking Decreased Drinking Weight Loss Weight Gain Itching/Scratching Vomiting Diarrhea Urination Issues Lethargy Behavioral Sneezing Coughing OtherPlease explain:*What brand and type of food do you feed your cat?*How much/how often do you feed your cat?* Free Fed Measured AmountsIs your cat on any current medications or supplements?* Yes NoIf so, what name, dose and frequency of medications?Do you have pet insurance?* Yes NoIf so, what type of insurance does your cat have?*Do you have our app (Vitus Vet)?* Yes NoIN PERSON VISIT – We ask that you remain seated for the examination and allow our trained assistants to provide physical support for your catIF YOU ARE ILL OR HAVE BEEN EXPOSED TO SOMEONE WHO IS ILL, WE WILL NEED YOU TO REMAIN CURBSIDE OR RESCHEDULE YOUR APPOINTMENT* I understand and agreeOwner Signature*Δ
