Name: Fairwood Plaza Animal Clinic
Address: 14410 SE Petrovitsky Rd #103, Renton, WA, 98058, USA

This form is intended for patients that have a scheduled appointment. If you do not have an appointment please click HERE to schedule or call us at 425-226-9960. We look forward to caring for your pet.

Please fill out this form prior to your appointment to help speed up the check in process.

Patient Name*
Owner name*
First Last
Person bringing patient in (if different than owner)
First Last
Date of appointment*
MM slash DD slash YYYY
Time of appointment*

: Hours

Minutes

AM/PM
Phone number for the appointment*
This is the number the doctor will call to discuss exam findings.
Are you bringing your pet in for one of the following? Please select one:*
- New Cat/Kitten
- New Dog/Puppy
- Vomiting/Diarrhea
- Limping
- Lump
- Skin and Ears
- Urinary Issues
- Wellness
- Eyes
- Other/General Problem
** We recommend routine parasite screenings for all patients, please bring a fresh fecal sample with you to your appointment. **
New cat/Kitten
How long have you had the patient?*
How did you obtain the patient?*
- Shelter
- Rescue
- Breeder
- Other
Please explain*
Do you have any previous records?*
- Yes
- No
If you do please bring with you or email to us at records@fpacvet.com
Has the patient been tested for FIV or Feline Leukemia?*
- Yes
- No
What were the results and where was it done?*
Do you plan to spay/neuter if not already done?*
- Yes
- No
- Already spayed/neutered
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
Indoor/outdoor/both?*
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have a specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
New Dog/Puppy
How long have you had the patient?*
How did you obtain the patient?*
- Shelter
- Rescue
- Breeder
- Other
Please explain*
Do you have any previous records?*
- Yes
- No
If you do please bring with you or email to us at records@fpacvet.com
Do you plan to spay/neuter if not already done?*
- Yes
- No
- Already spayed/neutered
Does the patient go on hikes or have access to areas where there is wildlife?*
- Yes
- No
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today?*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Vomiting/Diarrhea
Is there anything that the patient could have eaten they were not supposed to as garbage, toxins, toys, etc?*
- Yes
- No
Please explain*
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Has there been any change to the diet recently?*
- Yes
- No
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today?*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Limping
How long has the patient been limping?*
Which leg is affected?*
Are they putting any weight on the leg?*
- Yes
- No
- Sometimes
Is there any known trauma to the leg?*
- Yes
- No
Please explain*
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Lump
When did you first notice the lump?*
Where is the lump on the patient?*
Is the patient bothered by the lump?*
- Yes
- No
Has it increased in size?*
- Yes
- No
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Skin and ears
What areas of the skin is patient bothered by? (Check all that apply)*
- Eyes
- Ears
- Back
- Legs
- Belly
- Whole body
- Other
Please explain*
How long has the irritation been going on?*
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify
Which medication?*
Urinary issues
Check all that apply*
- Urinating more frequently
- Urinating inappropriately
- Painful or uncomfortable urination
- Urinating larger amount than normal
- Blood in urine
- Abnormal odor to urine
How long has the urinary issue been going on?*
Has the patient had urinary issues previously?*
- Yes
- No
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been defecating normally? (Check all that apply)*
- Abnormal bowel movements
- Bowel movements are normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Wellness
Has your pet had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Both
- Neither
How long?*
** Please bring a fresh fecal sample for possible parasite screening **
Has your pet had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Both
- Neither
How long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any other specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous around strangers?*
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today? Please select*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Eyes
What are the symptoms that the patient is experiencing?*
- Squinting
- Discharge
- Color change or cloudiness
- Other
Explain*
Which eye is affected?*
- Left
- Right
- Both
How long has this problem been going on?*
Is the patient itching or rubbing at the eye?*
- Yes
- No
Has the patient had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Neither
For how long?*
Has the patient had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Neither
For how long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous?
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today?*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication?*
Other/General Problem
Please describe the issue that the patient will be seen for:*
How long has this issue been going on?*
Has the patient had any vomiting or diarrhea?*
- Vomiting
- Diarrhea
- Neither
For how long?*
Has the patient had any coughing or sneezing recently?*
- Coughing
- Sneezing
- Neither
For how long?*
Is appetite and water drinking levels normal for patient? (Check all that apply)*
- Drinking is increased
- Drinking has decreased
- Eating has increased
- Eating has decreased
- Everything is normal for patient
Has the patient been urinating and defecating normally? (Check all that apply)*
- Abnormal urination
- Abnormal bowel movements
- Everything is normal for patient
Is patient itching or scratching?*
- Yes
- No
Please Explain*
Activity level normal for patient?*
- Yes
- No
Please Explain*
For cats, are they indoor only or do they go outside?
- Indoor only
- Goes outside
What type of food is patient eating?*
How much and how often are you feeding?*
Is the food grain free?*
- Yes
- No
- Unsure
Is the patient on any medications or over the counter supplements?*
- Yes
- No
What are they taking? How much? How often?*
Is the patient on any flea and parasite prevention?*
- Yes
- No
Which one?*
Do you have any specific concerns that you would like addressed?*
Is there any other information you feel we should know about your pet such as prefers women or is nervous?
Would you like an estimate for services or medication presented to you at the time of your appointment?*
- Yes
- No
Do you need any additional services today?*
- Medication refill
- Refill of flea and parasite prevention
- Other
- None
Please specify*
Which medication*
CAPTCHA

New cat/Kitten

New Dog/Puppy

Vomiting/Diarrhea

Limping

Lump

Skin and ears

Urinary issues

Wellness

Eyes

Other/General Problem