Medical Concern Form

Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.
We now offer in-person visits to fully vaccinated individuals (final COVID vaccine administered at least 14 days prior to the appointment). Please bring your proof of vaccination or Excelsior Pass with you to the visit. We ask that only one fully vaccinated adult be present at your pet’s exam since our exam rooms are too small to accommodate many people. We encourage the use of masks and ask that you provide emotional support for your pet while a patient handler provides physical support.
The check-in and check-out processes will still occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!

We will call you for a curbside visit. Do you have an iPhone for a video call or an Android for a video exam? *

Yes
No

If the infection rates allow it, would you prefer an in-person visit? *

In-Person Visit
Call

**Please bring your proof of vaccination or Excelsior Pass with you to the visit. We ask that only one fully vaccinated adult be present at your pet’s exam since our exam rooms are too small to accommodate many people.**

Owner's Name *

First

Last

Phone *

Email *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

What is the name and phone number of the contact who will make medical decisions today? *

Pet's Name *

Are there any concerns for the following: (check all that apply)

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

Please explain:

Is your pet on any medications? *

Yes
No

If Yes, please list all medications (prescribed or over the counter) and the time of last administration:

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure, such as tenderness or upset stomach after vaccines? *

Yes
No

Please explain:

Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Guardian Animal Medical Center authorization to treat as discussed above. *

I have read and agree

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Yes
No

Please type your initials. *

Date *

We’ll be there when you need us.

Our Location

Our Hours

Contact Information