Memorial-610 Hospital for Animals

910 Antoine Drive
Houston, TX 77024


Patient History Form

Pet Owner (required)
First Name (required)
Last Name (required)
Owner Phone Number (required)

Primary Contact Name and Phone Number on appointment day (if different from Owner Name) (required)

Pet's Name (required)

Reason for Visit - My pet is here today for (required)

Wellness Visit (annual; semi-annual) (If your pet is ill/has medical concerns, please select another box)
Follow-up Visit**
Illness Visit (problem-based)**

Overall well-being, weight, appetite, thirst, and eliminations (required)


If Abnormal, explain

Daily diet (brand + dry or canned), frequency of feeding, and when your pet last ate (required)

List medications you are currently administering to your pet, including heartworm prevention, flea control, supplements, and when dose(s) were last given (required)

I need the following medication(s) refilled (required)

-> **FOR ILLNESS VISITS or FOLLOW-UP ONLY: Please explain the problem *and* how long it has been going on (and if the patient is doing better, worse or the same)

For vaccine appointments: Has your pet had prior reactions to the requested vaccines or treatments?

Cats Only -- My cat primarily lives


Day Patient ("Drop Off") Information

If you require an estimate, please discuss this with a service representative or nurse *before* dropping off your pet.

Day patient discharge times are typically between 4 and 6 p.m. Please do not pick up your pet until a doctor or nurse has communicated with you that your pet is ready. We are unable to guarantee a specific discharge time due to the veterinary team's surgery, inpatient, and urgent patient priorities. Thank you for your understanding.

**Day patients are evaluated (triaged) based on severity/complexity of the problem, then by order of arrival. Critical and anesthetic/surgery patients receive priority attention. Thank you for understanding. **
CPR Authorization: In the unlikely event that complications develop and your pet’s breathing and/or heart stop while in our care, do you want us to perform CPR (resuscitation)?
(** Please understand that in the event your pet requires CPR, additional charges will incur for treatments utilized during CPR.)


Client/Authorized Signature (Please type your first and last name) (required)

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