Free · Unbranded · Medical records
A clean, two-page SOAP note for exam-room documentation. Vitals and a body-systems checklist up front, then a structured assessment and plan with a medication table, so nothing important gets lost between the exam and the record.
Unbranded: no logo or linksNo account neededPrint at 100% on US LetterUpdated
What’s on the form
Patient signalment, weight, date, clinician, and visit type, so the note can stand on its own in the chart.
Presenting complaint, history, and quick boxes for appetite, thirst, urination, stool, vomiting, and energy, plus current medications and diet.
Ten vitals fields (T, HR, RR, BCS, pain score, mucous membranes, CRT, hydration, mentation) and a 12-system exam checklist: normal, abnormal, or not examined.
Problem list, differentials, and a prognosis selector, written as clinical reasoning rather than a restatement of findings.
Diagnostics, treatment, a medication table with dose, route, frequency and duration, client communication, and the recheck date.
Clinician signature and date, so the record shows who wrote it and when.
Fill in online
Every line on the form is editable right here. When you’re done, print it or choose “Save as PDF” in the print dialog. Everything stays in your browser.
Click any line to type, or add your logo. Nothing is uploaded or saved.
Using it well
The assessment is where you connect findings to a problem list and differentials. "Vomiting, r/o dietary indiscretion vs. pancreatitis" is more useful later than "patient is sick".
A "not examined" box is honest documentation. Leaving a system blank reads as an omission; marking it shows a deliberate choice.
A line on what was discussed (estimate, prognosis, home care) closes the most common gap in records when questions come up later.
Skip the blank page
Record the exam and VetStack drafts a structured SOAP note in under a minute, ready to review and paste into your PIMS.
Printing, editing, and what the form does and doesn’t cover.
Subjective, Objective, Assessment, Plan. Subjective is the history and what the owner reports; Objective is measurable exam findings and test results; Assessment is your interpretation (problem list and differentials); Plan is diagnostics, treatment, client communication, and follow-up.
Yes. Use the fill-in version on this page: type into any field, then print or save it as a PDF from the toolbar. Nothing you type is uploaded or stored.
Many practices still keep paper or scanned records. What your state requires a medical record to contain varies, so check your state veterinary practice act for the specific required elements.
The top of page one has a blank clinic block for a stamp or label. You can also fill in the clinic name online before printing.
1 page, US Letter, portrait
A one-page, nose-to-tail physical exam form. Fourteen body systems with normal, abnormal and not-examined boxes, room for findings on every line, and the scores you actually record: BCS, muscle condition, pain and dental grade.
2 pages, US Letter, portrait
A take-home sheet clients can actually follow: what was done, every medication with dose and timing, feeding and activity rules, incision care, and a clear list of signs that mean "call us now".
2 pages, US Letter, landscape
A landscape anesthesia record built the way monitoring actually happens: pre-anesthetic checks and every drug on page one, then a 5-minute vitals grid, the procedure timeline, and recovery on page two.
A starting point, not legal or clinical advice. VetStack’s forms are general templates. Requirements for medical records, consent, and controlled substances vary by state and practice, so review the wording with your practice’s attorney and check your state veterinary board’s rules before adopting a form as standard.