Home » Client Information and Pet Medical History

Client Information and Pet Medical History

Welcome to Old Mill Veterinary Hospital! We are thrilled and honored that you have selected Old Mill Veterinary Hospital as your partner in the lifetime care of your beloved furry family members! You can be confident in the quality and excellence of the medical care we provide. Old Mill has been in the business of general practice veterinary care for pet owners in the Leesburg and Loudoun areas for over twenty-five years. We are proud to have been accredited by the American Animal Hospital Association for over twenty years. Our staff are composed of seven DVM’s, eight licensed veterinary technicians, multiple veterinary assistants with years of experience, and a warm, knowledgeable and welcoming team of receptionists to help you in any way we can!

Client Information and Pet Medical History

Please select the below options(Required)

For current clients click here

For new clients click here

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New Clients

New Clients Form:

Date(Required)

Name(Required)

First

Last

To be sure that we recommend the most appropriate care for your pet(s) and to avoid any lapses in critical services, it is very important that we have all of your pets’ past medical history including vaccination records at least 48 hours before your initial appointment with one of our veterinarians.

The most effective way is that we can obtain these records for you from your previous veterinary practice. Please complete this information.

Veterinary Hospital/ Doctor(Required)

Phone(Required)

Alternatively, you can provide us with a scanned or emailed copy of ALL records 48 hours before your scheduled appointment with Old Mill. Send or scan records to [email protected]. We must receive previous records at least 48 hours prior to the initial visit or additional visits may be required to complete all care needs.

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Medical Records Section – End

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New Clients – End

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Current Clients- Start

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Pet #1 Medical History/Current Concerns

Pet #2 Medical History/Current Concerns

Pet #3 Medical History/Current Concerns

Pet #4 Medical History/Current Concerns

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Pet 1 Section – Start

Please fill the Pet #1 Medical History/Current Concerns details

Please include the name of the primary owner on your pet’s account

Owner's First Name(Required)

Owner's Last Name(Required)

Does your pet need a medication refill?(Required)

Yes

Please indicate the name of the medication needed(Required)

Pet's Name(Required)

Best Phone Number to Contact You(Required)

Best Email to Contact You(Required)

Please have this form completed before coming to the hospital. This will help during the check in process, please include if you need a refill of medications or any questions that you may have for the doctor.

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.(Required)

Has your pet had any coughing?(Required)

Yes

Has your pet had any sneezing?(Required)

Yes

Does your pet have any nasal discharge?(Required)

Yes

If yes, what color and which nostril(s)?(Required)

Has your pet been vomiting?(Required)

Yes

If your pet has been vomiting, when was the last time and describe the vomit?(Required)

Has your pet had diarrhea?(Required)

Yes

Does your pet's stool look normal?(Required)

Yes

Is it black or bloody?(Required)

Yes

This case should not wait. Please call us at (703) 779-2903.

Please describe abnormal stool(Required)

Has your pet been drinking more?(Required)

Yes

Has your pet been urinating more?(Required)

Yes

Have you seen your pet's urine?(Required)

Yes

If so, what was the color and amount?(Required)

Has your pet's appetite changed?(Required)

Yes

If so, please describe how(Required)

When was the last time you saw a bowel movement and what did it look like?(Required)

Any change in diet?(Required)

Yes

If so, when and what did you change?(Required)

Is your pet lethargic?(Required)

Yes

If so, how long?(Required)

Is your pet here because it is limping?(Required)

Yes

If so, which leg and how long?(Required)

Please list all medications your pet is on and when they were last given(Required)

Has your pet cried out?(Required)

Yes

If so, what was your pet doing when this occurred?(Required)

Does your pet have a problem with one or both of its eyes?(Required)

Yes

If so, which eye? Describe any drainage or symptoms.(Required)

Does your pet have a problem with one or both of its ears?(Required)

Yes

If so, which ear? Describe any discharge or symptoms.(Required)

Do you have a concern with your pet's teeth?(Required)

Yes

If yes, please describe(Required)

Are there any new lumps or bumps you have found?(Required)

Yes

If so, where are they and how long have they been present?(Required)

Please use this area to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.(Required)

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Pet 1 Section – End

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Pet 2 Section – Start

Please fill the Pet #2 Medical History/Current Concerns details

Please include the name of the primary owner on your pet’s account

Owner's First Name(Required)

Owner's Last Name(Required)

Does your pet need a medication refill?(Required)

Yes

Please indicate the name of the medication needed(Required)

Pet's Name(Required)

Best Phone Number to Contact You(Required)

Best Email to Contact You(Required)

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.(Required)

Has your pet had any coughing?(Required)

Yes

Has your pet had any sneezing?(Required)

Yes

Does your pet have any nasal discharge?(Required)

Yes

If yes, what color and which nostril(s)?(Required)

Has your pet been vomiting?(Required)

Yes

If your pet has been vomiting, when was the last time and describe the vomit?(Required)

Has your pet had diarrhea?(Required)

Yes

Does your pet's stool look normal?(Required)

Yes

Is it black or bloody?(Required)

Yes

This case should not wait. Please call us at (703) 779-2903.

Please describe abnormal stool(Required)

Has your pet been drinking more?(Required)

Yes

Has your pet been urinating more?(Required)

Yes

Have you seen your pet's urine?(Required)

Yes

If so, what was the color and amount?(Required)

Has your pet's appetite changed?(Required)

Yes

If so, please describe how(Required)

When was the last time you saw a bowel movement and what did it look like?(Required)

Any change in diet?(Required)

Yes

If so, when and what did you change?(Required)

Is your pet lethargic?(Required)

Yes

If so, how long?(Required)

Is your pet here because it is limping?(Required)

Yes

If so, which leg and how long?(Required)

Please list all medications your pet is on and when they were last given(Required)

Has your pet cried out?(Required)

Yes

If so, what was your pet doing when this occurred?(Required)

Does your pet have a problem with one or both of its eyes?(Required)

Yes

If so, which eye? Describe any drainage or symptoms.(Required)

Does your pet have a problem with one or both of its ears?(Required)

Yes

If so, which ear? Describe any discharge or symptoms.(Required)

Do you have a concern with your pet's teeth?(Required)

Yes

If yes, please describe(Required)

Are there any new lumps or bumps you have found?(Required)

Yes

If so, where are they and how long have they been present?(Required)

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Pet 2 Section – End

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Pet 3 Section – Start

Please fill the Pet #3 Medical History/Current Concerns details

Please include the name of the primary owner on your pet’s account

Owner's First Name(Required)

Owner's Last Name(Required)

Does your pet need a medication refill?(Required)

Yes

Please indicate the name of the medication needed(Required)

Pet's Name(Required)

Best Phone Number to Contact You(Required)

Best Email to Contact You(Required)

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.(Required)

Has your pet had any coughing?(Required)

Yes

Has your pet had any sneezing?(Required)

Yes

Does your pet have any nasal discharge?(Required)

Yes

If yes, what color and which nostril(s)?(Required)

Has your pet been vomiting?(Required)

Yes

If your pet has been vomiting, when was the last time and describe the vomit?(Required)

Has your pet had diarrhea?(Required)

Yes

Does your pet's stool look normal?(Required)

Yes

Is it black or bloody?(Required)

Yes

This case should not wait. Please call us at (703) 779-2903.

Please describe abnormal stool(Required)

Has your pet been drinking more?(Required)

Yes

Has your pet been urinating more?(Required)

Yes

Have you seen your pet's urine?(Required)

Yes

If so, what was the color and amount?(Required)

Has your pet's appetite changed?(Required)

Yes

If so, please describe how(Required)

When was the last time you saw a bowel movement and what did it look like?(Required)

Any change in diet?(Required)

Yes

If so, when and what did you change?(Required)

Is your pet lethargic?(Required)

Yes

If so, how long?(Required)

Is your pet here because it is limping?(Required)

Yes

If so, which leg and how long?(Required)

Please list all medications your pet is on and when they were last given(Required)

Has your pet cried out?(Required)

Yes

If so, what was your pet doing when this occurred?(Required)

Does your pet have a problem with one or both of its eyes?(Required)

Yes

If so, which eye? Describe any drainage or symptoms.(Required)

Does your pet have a problem with one or both of its ears?(Required)

Yes

If so, which ear? Describe any discharge or symptoms.(Required)

Do you have a concern with your pet's teeth?(Required)

Yes

If yes, please describe(Required)

Are there any new lumps or bumps you have found?(Required)

Yes

If so, where are they and how long have they been present?(Required)

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Pet 3 Section – End

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Pet 4 Section – Start

Please fill the Pet #4 Medical History/Current Concerns details

Please include the name of the primary owner on your pet’s account

Owner's First Name(Required)

Owner's Last Name(Required)

Does your pet need a medication refill?(Required)

Yes

Please indicate the name of the medication needed(Required)

Pet's Name(Required)

Best Phone Number to Contact You(Required)

Best Email to Contact You(Required)

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.(Required)

Has your pet had any coughing?(Required)

Yes

Has your pet had any sneezing?(Required)

Yes

Does your pet have any nasal discharge?(Required)

Yes

If yes, what color and which nostril(s)?(Required)

Has your pet been vomiting?(Required)

Yes

If your pet has been vomiting, when was the last time and describe the vomit?(Required)

Has your pet had diarrhea?(Required)

Yes

Does your pet's stool look normal?(Required)

Yes

Is it black or bloody?(Required)

Yes

This case should not wait. Please call us at (703) 779-2903.

Please describe abnormal stool(Required)

Has your pet been drinking more?(Required)

Yes

Has your pet been urinating more?(Required)

Yes

Have you seen your pet's urine?(Required)

Yes

If so, what was the color and amount?(Required)

Has your pet's appetite changed?(Required)

Yes

If so, please describe how(Required)

When was the last time you saw a bowel movement and what did it look like?(Required)

Any change in diet?(Required)

Yes

If so, when and what did you change?(Required)

Is your pet lethargic?(Required)

Yes

If so, how long?(Required)

Is your pet here because it is limping?(Required)

Yes

If so, which leg and how long?(Required)

Please list all medications your pet is on and when they were last given(Required)

Has your pet cried out?(Required)

Yes

If so, what was your pet doing when this occurred?(Required)

Does your pet have a problem with one or both of its eyes?(Required)

Yes

If so, which eye? Describe any drainage or symptoms.(Required)

Does your pet have a problem with one or both of its ears?(Required)

Yes

If so, which ear? Describe any discharge or symptoms.(Required)

Do you have a concern with your pet's teeth?(Required)

Yes

If yes, please describe(Required)

Are there any new lumps or bumps you have found?(Required)

Yes

If so, where are they and how long have they been present?(Required)

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Pet 4 Section – End

Have you read and signed the Code of VA Amendment & VA Veterinary Disclosure form?(Required)

Yes

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Current Clients- End

Please upload any necessary pet records or documents here if applicable.(Required)

Drop files here or

Max. file size: 10 MB.

Code of Virginia Amendment

§ 54.1-3806-1 Disclosure forms required.

Any animal medical care facility in the Commonwealth, excluding those facilities dealing with livestock as defined in §3.1-796.66, which does not provide continuous medical care for all animals left in its charge shall, before taking charge of an animal, provide the client or agent thereof with a disclosure form which specifies the hours and days when continuous medical care is not available by the facility. Such form shall be separate and apart from any other form or information provided by the facility. Except in emergency situations when time or circumstances do not permit, such facilities may take charge of an animal only after the client or agent thereof has signed the disclosure form and returned it to the facility. Only one signed form per client shall be required, and the form shall be kept on file by the facility.

Code of Virginia Amendment

§ 54.1-3806-1 Disclosure forms required.

Virginia Veterinary Disclosure Form

(Please read carefully before signing.)

Old Mill Veterinary Hospital is continuously staffed by medical, kennel, and business personnel during the following hours:

Monday – Friday: 7am – 8pm

Saturday: 8am – 3pm

Continuous staffing is not provided at other hours or in major holidays; however, medical and kennel staff are present on a non-continuous basis each day to provide the proper care for your pet. Patients requiring continuous monitoring and medical treatment (i.e. intensive care) at times of noncontinuous staffing by this facility can be transferred by the owners or their agent to the Animal Emergency Center where after-hours staffing is provided. Any expenses incurred at the Animal Emergency Center will be the responsibility of the owner and will be payable to the Animal Emergency Center. I have read this form, and I am aware of the staffing hours.

Client First Name(Required)

Client Last Name(Required)

Client Email(Required)

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Signature Section

Date(Required)

Signature(Required)

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Client Information and Pet Medical History

Client Information and Pet Medical History

New Clients

New Clients Form:

Pet 1 Information

Pet 1 Information:

Pet 1 Information End

Pet 2 Information

Pet 2 Information:

Pet 2 Information End

Pet 3 Information

Pet 3 Information:

Pet 3 Information End

Pet 4 Information

Pet 4 Information:

Pet 4 Information End

Medical Records Section

Medical Records

Medical Records Section – End

New Clients – End

Current Clients- Start

Pet 1 Section – Start

Please fill the Pet #1 Medical History/Current Concerns details

Pet 1 Section – End

Pet 2 Section – Start

Please fill the Pet #2 Medical History/Current Concerns details

Pet 2 Section – End

Pet 3 Section – Start

Please fill the Pet #3 Medical History/Current Concerns details

Pet 3 Section – End

Pet 4 Section – Start

Please fill the Pet #4 Medical History/Current Concerns details

Pet 4 Section – End

Current Clients- End

Code of Virginia Amendment

Code of Virginia Amendment

Virginia Veterinary Disclosure Form

Signature Section

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