New Puppy/Kitten History Form

Welcome to Guardian Animal Medical Center!

Complete the form below so our team can get to know you and your pet before your appointment. If you need immediate assistance, please call or text us at 606-928-6566.

Owner Name *

First

Last

Phone *

Email *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Who should we contact to make medical decisions today? *

First

Last

At what number can they be reached today? *

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

iPhone
Android
Neither

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.**

Pet's Name *

Species *

Breed *

Color *

Age/date of birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

When did you get your pet? *

Where did you get your pet? *

Shelter
Breeder
Pet Store
Online
Friend
Other

If other, please specify *

What kind of food do you feed your pet? *

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount

Measured amount *

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

Sneezing
Coughing
Vomiting
Diarrhea
Eating
Drinking
Other

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

If other, please specify *

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

Please explain *

Is your pet on any medications? *

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

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 understand

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

I authorize

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days? *

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Coughing
Shortness of breath
Fever
Sore throat
Chills
Muscle pain
Headache
New loss of taste or smell

Who experienced these symptoms?

Self
Someone else in the house
No symptoms

*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.*

In-person visit: Please call or text our team when you arrive to check in. When the doctor is ready to examine your pet, a team member will escort you into the exam room. We ask that you remain seated during the exam and allow a trained patient handler to provide physical support to your pet. Wearing a mask is required. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we ask that you return to your vehicle while the doctor and nurses complete the services discussed (such as bloodwork, x-rays, or other therapies). As with curbside visits, we will call or send a secure link for payment after the visit is complete and bring your pet back to you. This will allow for proper cleaning time between patients to keep all of our patients, clients, and team members as healthy as possible. *

I have read and understand

Critter concierge: For fully curbside visits, during the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or nurse will call you in your vehicle to discuss your pet’s exam and discuss recommended treatments or preventative measures. *

I have read and understand

Day admission appointments: A day admission appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive. *

I have read and understand

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

Please type your initials. *

Date *

Please text photos of your pet's records to 606-928-6566 and/or bring any paperwork with you to the appointment so that your veterinarian knows which vaccines or treatments have already been started.

Comment

We’ll be there when you need us.

Our Location

918 Bellefonte Road
Flatwoods, KY 41139
Click here for directions.

Our Hours

Mon, Tues, Fri: 8:00AM – 6:00 PM
Wed: 8:00AM – 2:00PM
Thur: 8:00AM – 7:00PM
Sat: 8:00AM – 12:00PM
We will be closed on some Saturdays. Please contact us to confirm our hours.

Contact Information

Call/Text: 606-928-6566
E: GuardianAppt@gmail.com
Tri State Animal ER: 304-453-5700