Please note: We will be closed Christmas eve and Christmas Day. We will be closing at 3PM on New Years Eve. We will be closed on New Years Day. Happy Holidays!

Online Forms

Acupuncture Intake Form

Save time during your next appointment at Florence Animal Hospital! Complete your required forms online from any device at any time before your visit.

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Online Forms

Acupuncture Intake Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Patient Information

Name *

Animal type: *

Dog
Cat
Other

If other, please specify: *

Age/Date of Birth

If date of birth is unknown, please write approximate age.

Gender: *

Intact Male
Intact Female
Neutered Male
Spayed Female

Color/coat

Please list current medications, supplements, herbs, and preventative medications.

Please list your pet’s current diet including food, treats, and table scraps/human food (if any).

Are there any food or medication allergies or sensitivities?

No (or unknown)
Yes

If yes, please list below:

Main Complaint/Reason for Visit:

Previous medical history (conditions, injuries, diagnosis) or behavioral issues:

Please check all that apply and include additional information if available

Eyes

Discharge
Redness
Squinting
Vision Changes
Cataracts
Other

If other, please explain:

Ears

Discharge
Inflamation/Redness
Hearing Loss
Other

If other, please explain:

Nose

Discharge
Discolopration
Other

If other, please explain:

Mouth

Excessive tartar
Gingivitis (red gums)
Bad breath (halitosis)
Difficulty chewing
Excessive salivation
Other

If other, please explain:

Respiratory

Difficulty breathing
Excessive panting
Coughing
Sneezing
Nasal discharge
Other

If other, please explain:

Digestive

Vomiting
Diarrhea
Lack of appetite
Excessive appetite
Picky eater
Weight gain
Weight loss
Bad gas
Other

If other, please explain:

Skin/Hair coat

Dry
Greasy
Dandruff/flakes
Hair loss
Itchy
Sores/wounds
Other

If other, please explain:

Musculoskeletal

Back pain
Joint pain (arthritis)
Lameness/limping
Previous injuries
Joint swelling
Stiff/sore
Other

If other, please explain:

Activity

Increased activity
Decreased activity
Lethargic
Other

If other, please explain:

Urinary

Large amounts
Small amounts
Lethargic
Bloody
Increased frequency
Decreased frequency
Drinking more
Drinking less
Strong smell
Incontinence
Other

If other, please explain:

Feces

Loose/soft/watery
Dry
Constipated
Bloody
Increased frequency
Decreased frequency
Mucusy
Incontinence
Other

If other, please explain:

Sleep

Increased sleep
Decreased sleep
Restless sleep
Prefers soft bedding
Prefers hard surface
Other

If other, please explain:

Temperature

Prefers warm areas (sun, heater, blankets)
Prefers cool areas (cool tile, cement)
Other

If other, please explain:

Emotional

Depressed
Hyper excitable
Sociable
Hiding
Other

If other, please explain:

Ready to see us?

Please call to schedule an appointment today!

We proudly serve the pets of Omaha, Florence, Fort Calhoun, Crescent IA, Ponca Hills, Raven Oaks, Benson, Omaha Country Club, Lake Cunningham, and beyond. Use the button below to request an appointment with us.

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Contact Us

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Contact Information

Phone: 402-451-7001
Email: info@florenceanimalhospital.net

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Hours

Mon – Fri: 8 AM to 5:30 PM
Sat: 8 AM to 12 PM

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Address

8305 N 30th St.
Omaha, NE 68112

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Ask us a question and we will get back to you within business hours.

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