Veterinary Clinic Software with a Ready-Made Animal Patient Record

Fourteen Sections, from the Owner to Consent

The template's sections follow the order of a veterinary visit. Every record also holds the basic details, such as the name, date of birth, and contact details, which are entered once and never requested again inside the form.

• Owner: the name, the relationship to the animal (owner, temporary carer, or shelter), and an alternative contact
• Animal identification: species, breed, color, reproductive status, microchip, and passport
• History: the reason for the visit, how long the signs have lasted, appetite and water, vomiting or diarrhea, coughing, and past illness
• General history: allergies, pregnancy or nursing, medication, diet, living environment, contact with other animals, and travel
• Vaccination: the status and a register with the date, vaccine, product, batch, and next due date
• Parasite control: internal, external, and heartworm treatments, with the next treatment
• Vital signs: weight, temperature, heart rate, breathing rate, gums, hydration, body condition, and pain
• Examination by system: skin, eyes and ears, mouth, lymph nodes, heart and lungs, abdomen, bones and muscles, and the nervous and urinary systems
• Clinical photography: a photo of the finding and a follow-up photo, each with its own date
• Tests and imaging: the type, date, result, and findings
• Assessment and plan: the diagnosis, differential diagnoses, prognosis, plan, advice to the owner, and next check-up
• Anesthesia and surgery: the procedure, weight, protocol, complications, and aftercare
• Medication and treatment: what was given or prescribed, and a visit log with the weight each time
• Owner consent: a ready-written statement your clinic can edit, signed by the owner and the veterinarian

Species, Breed, and Microchip, Recorded Clearly

Pick the species from a list: dog, cat, rabbit, bird, small rodent, reptile, horse, or other. Breed, color, and distinguishing marks are typed freely, and reproductive status is chosen from intact, spayed or neutered, and unknown.

The microchip number has its own field, with a note that it has 15 digits under the ISO standard, and the animal's passport number is kept in another. The animal's sex comes from the basic details at the top of the record.

The question "Caution: bites or aggressive?" is marked as safety-critical. When the answer is yes, it appears at the top of the record on screen, with any note typed beneath it, and is repeated in a separate box on the first page of the PDF.

The Owner Is the Contact, Not a Minor

In the basic details, the first name is the animal's name, the last name is the owner's surname, and the phone, email, and address are the owner's, so messages reach the person who receives them. The owner section explains this on screen.

The template is marked as a template for animals, so the consent to be contacted is given by the owner, and no parent or guardian has to be named, even though almost every animal is under eighteen. The contact buttons at the top of the record call the owner the animal's guardian and add the animal's name.

You get the same choice when you build a new template yourself, with the box "This template is for animals".

Vaccines and Parasites, with the Next Date

Record each vaccine with its date, name, product, and batch, together with the next booster date, in a table that takes as many rows as you need. Parasite treatments sit in a separate table, divided into internal (worms), external (fleas and ticks), heartworm, or combined.

The next dates are stored in the record for your staff to see, but they do not start a reminder on their own. The automatic email reminder is for the next check-up, counted from the last visit, for owners who agreed to be contacted, once you turn it on. Six months is the default interval, and you can change it.

• Appointment Calendar

Vital Signs and the Examination, System by System

The vital signs section collects the weight, temperature, heart rate and breathing rate, capillary refill time, gum color, and hydration. Body condition is recorded on a scale of 1 to 9, with 4 to 5 as the ideal, and pain on a scale of 0 to 5.

The examination continues with nine free text fields, from skin and coat to the urinary and genital systems, where the veterinarian writes the findings for each system. Add the weight of each visit to the visit log as well, so the change shows from one visit to the next.

Tests and Surgery, Opened Only When Needed

The tests and anesthesia sections close themselves when their first question is answered no, and the date, type, and other fields are no longer requested. Tests record the type (bloodwork, urinalysis, a fecal test, a rapid test, X-ray, ultrasound, or cytology), the date, an image of the result, and the findings.

For a surgery, enter the procedure, the weight before anesthesia, the anesthetic protocol, complications, and aftercare. Photos of the finding and the follow-up go in the photography section, each with its own date.

Diagnosis, Prognosis, and Medication

The assessment section holds the diagnosis, differential diagnoses, the prognosis (good, guarded, or poor), the treatment plan, advice to the owner, and the date of the next check-up.

Medication given or prescribed goes into a table with the date, the medication, the dose and route, and the duration.

The Owner's Consent, Written for the Animal

The statement has seven clauses and speaks of the animal, not of a patient: being informed about the diagnosis, sedation or anesthesia, risks and costs, a declaration of ownership, authority for treatment and urgent measures, and the right to refuse. In the template's text, the authority for urgent measures does not include euthanasia, which is carried out only with the owner's separate agreement.

The owner signs on screen with a finger or a mouse, and so does the veterinarian. If the consent was signed on paper, upload a photo of the signature, and the PDF notes that it came from paper.

The text is a starting point. Your clinic reads it with its veterinarian and a lawyer, changes it as needed, and uses it only once it has been adapted.

Records in Albanian and a Second Language

The animal's patient record prints in Albanian with a second language beside it: English, Italian, French, or Spanish. The template comes with its wording in all four, including the dropdown answers and the consent, and your clinic can review and change all of it.

• Patient Record Templates by Specialty