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Overview

Patient records are the foundation of your veterinary practice in Paw & Care. This guide walks you through creating a complete patient profile, including demographics, medical history, vaccinations, and photos.
In Paw & Care, “patients” are the pets, and “clients” are the pet owners. Each patient must be linked to a client/owner record.

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What You’ll Learn

  • Creating pet owner (client) records
  • Adding patient demographics and identifiers
  • Recording medical history, conditions, and allergies
  • Uploading and managing patient photos
  • Tracking vaccinations with automated reminders
  • Managing multi-pet households

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Prerequisites

Before adding your first patient:
  • ✅ Completed the onboarding process
  • ✅ Have the iOS app or web access
  • ✅ (Optional) Have a photo of the pet ready to upload

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Step 1: Create the Pet Owner (Client) Record

Every patient must have an associated owner. You’ll create the owner first, then link the pet.
1

Navigate to Clients Section

On iOS: Tap More tab → ClientsOn Web: Click Clients in the left sidebar
2

Add New Client

  1. Tap/Click the + New Client button (top right)
  2. A client form will open
3

Enter Client Information

Fill in the following details:Basic Information
  • First Name: Sarah
  • Last Name: Johnson
  • Email: [email protected]
  • Phone: (555) 123-4567
  • Address (optional): 123 Oak Street, Springfield, IL 62701
Communication Preferences
  • Preferred Contact Method: Select from dropdown
    • Phone (default for urgent matters)
    • Email (good for appointment confirmations)
    • SMS (best for quick reminders)
Emergency Contact (optional but recommended)
  • Emergency Contact Name: John Johnson
  • Emergency Phone: (555) 987-6543
  • Relationship: Spouse
Emergency contacts are crucial if the owner is unreachable during a crisis. Always try to collect this information during check-in.
4

Set Client Source and Status

Source: How did this client find you?
  • AI Call (Luna booked appointment)
  • Walk-in
  • Website
  • Referral (ask who referred them)
Status: Current relationship stage
  • New Client (default for first-time patients)
  • Contacted
  • Appointment Booked
  • Regular Client
  • Churned
The system automatically updates status as the relationship progresses.
5

Add Client Notes (Optional)

Use the Notes field for important context:
- Prefers morning appointments
- Very anxious about medical procedures
- Requested reminder calls 48 hours in advance
- Has two dogs (Max and Bella)
These notes appear whenever you interact with this client.
6

Save Client Record

  1. Review all information for accuracy
  2. Click Create Client
  3. You’ll see a success message: “Client Sarah Johnson created successfully”
  4. The system generates a unique client ID automatically

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Step 2: Add the Patient (Pet) Record

1

Navigate to Pet Records

On iOS: Tap Patients tab at the bottomOn Web: Click Pet Records in the left sidebar
2

Create New Patient

  1. Tap/Click the + Add Patient button
  2. The new patient form opens
3

Link to Owner

Select Owner:
  1. Start typing “Sarah” in the Owner field
  2. Select Sarah Johnson from the dropdown
  3. The system auto-fills owner contact information
If the owner doesn’t exist yet, you can click Create New Owner directly from this field.
4

Enter Basic Demographics

Required Fields:
  • Name: Max
  • Species: Select from dropdown
    • Dog ✓
    • Cat
    • Bird
    • Rabbit
    • Reptile
    • Exotic
    • Other
  • Breed: Beagle (free text, with autocomplete suggestions)
  • Color: Brown and white
  • Sex: Male
  • Date of Birth: 03/15/2018 (or enter age: 5 years)
  • Weight: 28 lbs (system converts to kg automatically: 12.7 kg)
The system automatically calculates:
  • Current age from date of birth
  • Age in years and months
  • Last updated date
5

Add Identifiers and Status

Neutered/Spayed:
  • ✅ Yes, neutered (check the box)
  • Date: 05/20/2018
Microchip:
  • ✅ Yes, microchipped (check the box)
  • Microchip ID: 985112001234567 (15-digit number)
  • Microchip Brand: HomeAgain (dropdown)
Patient Status:
  • Active ✓ (default)
  • Deceased
  • Transferred (to another clinic)
Always verify microchip IDs against national databases (e.g., AAHA Universal Pet Microchip Lookup) to ensure accuracy.
6

Record Medical History

Known Conditions: Click Add Condition
  • Seasonal allergies
  • Mild hip dysplasia
  • History of ear infections
Each condition appears as a red badge on the patient card.Allergies (Critical for Safety): Click Add Allergy
  • Penicillin (⚠️ Drug allergy)
  • Chicken (Food allergy)
  • Pollen (Environmental)
These display prominently with orange warning badges.Current Medications: Click Add Medication
  • Rimadyl 75mg (1 tablet daily for hip dysplasia)
  • Apoquel 16mg (1 tablet daily for allergies)
Drug allergies and current medications are shown at the top of every record to prevent dangerous interactions.
7

Add Diet and Care Notes

Diet Notes (free text):
- Royal Canin Medium Adult dry food (2 cups daily)
- No chicken or poultry products due to allergy
- Occasional green beans as treats
- Maintain weight between 26-30 lbs
These notes help technicians and other vets provide consistent care.
8

Upload Patient Photos

On iOS (Recommended):
  1. Scroll to Photos section
  2. Tap Take Photo to use camera, or Choose Photo for gallery
  3. Frame the pet clearly (face shots work best)
  4. Tap Use Photo
  5. Add a caption: “Max - Front view (March 2026)”
  6. Toggle Set as Primary Photo (this appears on patient cards)
On Web:
  1. Click Upload Photos
  2. Drag and drop image files (PNG, JPG, HEIC)
  3. Or click to browse your computer
  4. Maximum 10 photos per patient
  5. Maximum 5 MB per photo
Best Practices:
  • Take photos in good lighting
  • Capture identifying features (coat patterns, scars, etc.)
  • Update photos annually for identification
  • Use photos to document skin conditions, wounds, or dental issues
Photos help staff quickly identify patients during check-in, especially in multi-pet households or busy practices.
9

Assign Primary Veterinarian (Optional)

If this patient has a preferred vet:
  1. Click Assign Vet dropdown
  2. Select Dr. Sarah Wilson
  3. This vet will be auto-selected for future appointments
Useful for:
  • Continuity of care
  • Specialty cases
  • Building vet-client relationships
10

Review and Save

  1. Scroll through the entire form to verify accuracy
  2. Required fields are marked with red asterisks (*)
  3. Click Create Patient
  4. Success message: “Max has been added to your patient database”
  5. You’re taken to Max’s patient profile page

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Step 3: Add Vaccination Records

1

Open Vaccination Tab

From Max’s patient profile:
  1. Tap/Click the Vaccinations tab
  2. You’ll see an empty vaccination history
2

Add First Vaccination

Click + Add VaccinationVaccine Details:
  • Vaccine Name: DHPP (Distemper, Hepatitis, Parvovirus, Parainfluenza)
  • Date Administered: 03/15/2023
  • Administered By: Dr. Sarah Wilson (dropdown)
  • Batch Number: 2023-DHPP-4567 (from vaccine vial)
  • Manufacturer: Merck (optional)
  • Next Due Date: 03/15/2026 (system calculates based on vaccine type)
Status (auto-calculated):
  • ✅ Current (green badge)
  • ⚠️ Due Soon (yellow badge, within 30 days)
  • ❌ Overdue (red badge)
  • Expired
3

Add Common Vaccinations

Repeat for standard dog vaccinations:Rabies
  • Date: 03/15/2023
  • Next Due: 03/15/2026 (3-year)
  • Status: Current ✅
Bordetella
  • Date: 09/01/2025
  • Next Due: 09/01/2026 (annual)
  • Status: Current ✅
Leptospirosis
  • Date: 03/15/2025
  • Next Due: 03/15/2026
  • Status: Due Soon ⚠️
The system will automatically send vaccination reminders to owners 30 days before the due date.
4

Set Up Automated Reminders

For each vaccine marked “Due Soon”:
  1. The system queues an email/SMS reminder to Sarah Johnson
  2. Message preview: 
    Hi Sarah,

Max's Leptospirosis vaccine is due on March 15, 2026.
Please schedule an appointment at your convenience.

Paw & Care Veterinary Clinic
(555) 555-1234
  3. Owner receives reminders at 30 days, 14 days, and 7 days before due date
You can customize reminder schedules in Settings → Communication Preferences.

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Step 4: Verify Patient Profile

1

Review Patient Card

Navigate back to Pet Records list.Max’s patient card should display:Top Section:
  • 🐕 Species emoji
  • Name: “Max”
  • Breed: “Beagle”
  • Active status badge (green)
Demographics Grid:
  • Age: 5 yrs
  • Weight: 28 lbs
  • Sex: Male
Conditions (red badges):
  • Seasonal allergies
  • Mild hip dysplasia
  • History of ear infections
Allergies (orange badges with ⚠️):
  • ⚠️ Penicillin
  • ⚠️ Chicken
  • ⚠️ Pollen
Owner Info:
  • Owner: Sarah Johnson
2

Test Search and Filters

  1. Go to Pet Records screen
  2. Use the search bar:
    • Type “Max” → Should find immediately
    • Type “Beagle” → Should find by breed
    • Type “Sarah” → Should find by owner name
  3. Test filters:
    • Species: Select “Dog” → Shows only dogs
    • Status: Select “Active” → Hides deceased/transferred pets
    • Clear Filters: Returns to full list
Search is real-time and searches across patient names, breeds, species, and owner names simultaneously.
3

Mobile Quick Actions

On iOS, tap and hold Max’s patient card to reveal quick actions:
  • 📞 Call Owner → Dials Sarah Johnson
  • 📅 Book Appointment → Pre-fills Max and Sarah
  • 🩺 New Record → Starts dictation/SOAP for Max
  • 📝 View History → Shows all medical records

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Adding Multi-Pet Households

Many clients have multiple pets. Here’s how to handle that:
1

Add Second Pet for Same Owner

  1. Create new patient: + Add Patient
  2. Owner: Select “Sarah Johnson” (already exists)
  3. Enter details for Bella:
    • Name: Bella
    • Species: Dog
    • Breed: Golden Retriever
    • Age: 3 years
    • Weight: 65 lbs
2

View All Owner's Pets

From Client Record:
  1. Go to Clients → Sarah Johnson
  2. Scroll to Pets section
  3. You’ll see cards for both Max and Bella
  4. Click either to jump to that patient’s profile
From Patient Record:
  1. Open Max’s profile
  2. Click Owner: Sarah Johnson
  3. View all her pets in one place
3

Book Multi-Pet Appointments

When scheduling:
  1. Create appointment for Max at 10:00 AM
  2. Create appointment for Bella at 10:30 AM
  3. Both linked to Sarah Johnson
  4. She receives one consolidated reminder for both appointments

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Best Practices for Patient Records

Keep Records Current

  • Update weight at every visit
  • Add new conditions as diagnosed
  • Remove medications when discontinued
  • Take updated photos annually

Document Thoroughly

  • Record all allergies, even mild ones
  • Note behavioral issues (aggressive, anxious)
  • Document owner preferences
  • Add special handling instructions

Use Photos Wisely

  • Capture identifying features
  • Document wounds or skin conditions over time
  • Before/after photos for dental cleanings
  • Upload X-rays and lab results as attachments

Verify Identifiers

  • Confirm microchip IDs with scanner
  • Check national databases
  • Update if microchip number changes
  • Record tattoo IDs if present

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Common Scenarios

If the exact date of birth is unknown:
  1. Enter an approximate date (e.g., “January 1, 2020” if they’re “about 6 years old”)
  2. Or use the Age field to enter “6 years” directly
  3. Add a note in Diet/Care Notes: “Age is approximate, exact DOB unknown”
The system uses this for age calculations and vaccination schedules.
When taking over care from another vet:
  1. Create the patient record as usual
  2. In Notes, add: “Transferred from ABC Veterinary Clinic on [date]”
  3. Request medical records from previous clinic
  4. Manually enter past vaccinations with dates
  5. Upload received records as PDF attachments to medical records
  6. Mark historical vaccinations with “Administered by: ABC Veterinary Clinic”
If you accidentally create duplicate records:
  1. Contact [email protected] with both patient IDs
  2. Our team will merge the records (preserves all data)
  3. The duplicate record will be marked as merged
  4. All appointments and medical records transfer to the primary record
Do not delete duplicates yourself, as this removes all associated data permanently.
To mark a patient as deceased:
  1. Open the patient’s profile
  2. Click Edit Patient
  3. Change Status from “Active” to “Deceased”
  4. Enter Date of Death (optional but recommended)
  5. Add a note with cause if known
  6. The patient will no longer appear in active searches
  7. All medical records are preserved for reference
The owner can still view the patient in their client portal (if enabled) as a memorial.
For birds, reptiles, rabbits, and exotic pets:
  1. Select Species: Exotic (or specific type if available)
  2. Breed field: Enter specific species (e.g., “African Grey Parrot”)
  3. Weight: Use appropriate units (grams for small birds, ounces for rodents)
  4. Sex: May be “Unknown” if not determined
  5. Add species-specific care notes (temperature requirements, diet, habitat)
  6. Vaccination requirements vary by species

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Next Steps

Book First Appointment

Schedule Max for a wellness check with automated reminders

Create SOAP Note

Document your first examination using voice dictation

Import Existing Patients

Migrate patient data from your previous system in bulk

Daily Workflow

Learn the optimal workflow for busy clinic days

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Success Criteria

You’ve successfully created your first patient when:
  • ✅ Owner (Sarah Johnson) record exists with complete contact info
  • ✅ Patient (Max) linked to owner with all demographics
  • ✅ Medical history includes conditions, allergies, and medications
  • ✅ At least one photo uploaded and set as primary
  • ✅ Core vaccinations recorded with due dates
  • ✅ Patient appears in search and filters correctly
  • ✅ Quick actions work from patient card
Now that Max is in the system, you can book appointments, create SOAP notes, and track his complete medical history all in one place!

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