Client Intake Form

Thank you for choosing Austintown Veterinary Clinic to care for your pet. Filling out this form before your appointment will greatly assist us in adding you and your pet to our system. We will be happy to contact your previous veterinarian to obtain any necessary information or documentation regarding your pet's medical history.

Pet Information

Pet Name*

Pet 1:
Pet 2:
Pet 3:

Species*

Pet 1:
Pet 2:
Pet 3:

Color/Markings*

Pet 1:
Pet 2:
Pet 3:

List Gender (Intact Male / Intact Female / Neutered Male / Spayed Female)*

Pet 1:
Pet 2:
Pet 3:

Age or Birthday*

Pet 1:
Pet 2:
Pet 3:

Do your pet(s) have any allergies? If yes, please list and specify which pet:

What medications are your pet(s) taking?
Please include: Drug Name & Strength / Dose / Frequency / Last Given / Refill Needed?

Does your pet(s) have insurance?*

Yes

We are happy to call your previous veterinarian to obtain a copy of your pet’s records.
Please provide us with the following information: Practice Name / City / State / Phone / Email

Owner Information

How did you hear about us?*

Drive by / Sign

Internet

Personal Referral

Other

Personal Referral: Is there a client, business or organization we can thank for your referral?

Please read each policy carefully and initial each section to acknowledge that you understand and agree to the policy.

I am the owner or authorized agent of the pet(s) listed on this form and have the authority to authorize veterinary care and treatment.

Payment is due at the time services are provided. I understand that I am responsible for payment of all services authorized for my pet.

I understand that appointment reminders are sent as a courtesy. I am responsible for confirming my pet's appointment when I receive the reminder. Beginning October 1, 2026, if I do not confirm my appointment by the confirmation deadline provided in the reminder, my appointment may be cancelled and the appointment time may be made available to another patient. If I have difficulty confirming my appointment or have questions about my appointment, I will contact Austintown Veterinary Clinic before the confirmation deadline.

I understand that if I do not confirm my scheduled appointment by the confirmation deadline provided by Austintown Veterinary Clinic, my appointment may be cancelled. I understand that it is my responsibility to contact the clinic if I have difficulty confirming my appointment. I also understand that if I do not show up for a scheduled appointment, I will be required to pay a deposit before scheduling another appointment.

I understand that Austintown Veterinary Clinic is committed to maintaining a safe and respectful environment for clients and staff. Swearing at, yelling at, threatening, or otherwise disrespecting team members is not acceptable.

I understand that dogs must be on a secure leash and cats and other small pets must be safely contained in an appropriate carrier while in or around the hospital.

I agree to inform the veterinary team of any known aggression, fear, bite history, or other behavior that could create a safety concern for my pet, other patients, clients, or staff. Appropriate precautions, including additional restraint or a muzzle, may be required.

I authorize Austintown Veterinary Clinic to request and/or release my pet's medical records to or from other veterinary hospitals as needed for continuity of care.

Please type your initials in agreement in each box below:*

I am the owner or agent for the animal described above, and I have the authority to execute this consent.
I understand that payment is due in full at the time services are rendered.