Mon-Fri: 5pm-8am
Sat-Sun: 24 hours
Holidays: 24 Hours

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PHONE: 503-588-8082

Emergency Intake Questionnaire

If you are on your way to our clinic or waiting to be seen, please fill out this form and submit it to us. Thank you!

Please note (unless it is a holiday and we have extended hours listed) we are CLOSED Monday through Friday from 8am to 5pm and will not be available during those hours. Visit our Resources page for links to all other veterinary clinics in the greater Salem/Keizer area if you need help when we are unavailable.

Questions with a star * beside them are required.

I understand the exam fee is $150 and does not cover any treatments or medications. I understand the exam fee increases to $200 during holiday weekends and between the hours of 12am & 9am every day.*

Owner Name(s): First and Last Name

Phone Number:

Additional Phone Number:

Address:

City, State:

If your City/State was NOT listed, please input here:

Zip Code:

Email Address:

Have you or anyone close to you been in contact with someone who has tested positive for COVID-19 within the last month?

Do you or anyone with you today have a recent history of respiratory illness?

Pet's Name:

Pet's Species:

Pet's Breed:

Pet's Color:

Pet's Age:

Pet is:

Pet's Primary Care Veterinary Clinic:

Is your pet current on vaccinations?

Pet's Current Diet or Brand of Food:

Please describe the reason for your pet's emergency or urgent care visit today.

Check any symptoms your pet is experiencing or has experienced recently:

Abnormal Behavior (describe above)

Bleeding

Bloody Urine / Stool / Vomit

Breathing Difficulty / Gasping

Constipation

Coughing

Decreased Appetite

Diarrhea

Difficulty Walking / Inability to Walk

Discharge (describe above)

Drooling

Excessive Thirst

Fever

Frequent Urination

Incontinence (leaking urine, unable to control bowels, etc)

Itching / Scratching

Lethargy / Depression

Limping / Not Weight Bearing

Not Eating / Not Drinking

Pain

Seizures / Involuntary Tremors

Shaking

Sneezing / Congestion

Straining or Inability to Urinate

Swelling / Inflammation

Unproductive Vomiting / Dry Heaving

Vomiting

Weight Loss (unintentional or unexplained)

No Symptoms Currently

*In Need of End of Life Care*

When did these symptoms start? Or when did the incident happen?

Any previous medical issues or diagnosed conditions?

Any recent changes in your pet's diet or environment?

Has your pet had reactions to vaccines or medications? Any known allergies or food sensitivities?

Is your pet currently taking medications (including supplements, vitamins, flea products, etc.)? Include dosage, how often medication is given, or last time dose was given.

My pet is transferring from another veterinary hospital:

Our clinic works on a system of triage and critical patients will be rushed into our hospital as quickly as possible. If your pet is currently stable, would you prefer to:

Drop off my pet

Have my pet wait with me until it is time for their exam

My pet may not be stable

I am parked in:

Color/Make/Model of your Vehicle: