Patient Intake Form

Tell us about your animal — before we meet.

This intake form helps us prepare for your visit so we can give your animal our full attention from the moment we arrive. Fill it out online (stays in your browser, no email app needed) or download the printable PDF.

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Fill it out online

Click the form below and complete it on this page. Your submission goes directly to XVC — you stay in your browser the whole time. No email app, no printing required.

PDF version

Prefer to print?

Download the 2-page printable PDF, fill it in, and bring it to your visit. Or scan and email back to XVetCare@gmail.com.

Download PDF →

Online intake

Online intake form.

Please fill out everything you can. Anything you’re unsure about — leave blank and we’ll cover it during the visit.

Visit details

Owner information

Patient (pet) information

Medical history

Reason for visit / chief complaint

Symptoms observed — check all that apply:

Consent & liability

Scope of services — please read. Xavier's Veterinary Care is operated by a Licensed Veterinary Technician (LVT), not a DVM. Services include wellness assessments, preventive care education, specimen collection, and mobile vet tech support. We do not diagnose, prescribe, or perform surgery. When a DVM is indicated, we will refer you.

By typing your name and submitting, you confirm the information above is accurate to the best of your knowledge.

Your information is sent directly to XVC. You stay on this page — no email app required. We will confirm receipt by email within one business day.