Three documents a clinic uses every day, ready to print or to adapt in Word: the patient's clinical history, the clinical report for a consultation and the report for referring a case to another clinic or a specialist. You download them without signing up and can use and adapt them in your clinic.
They are published by Artiprax, veterinary practice software that drafts the clinical report from your dictation. The templates do not need Artiprax: they work on paper and in any word processor.
Veterinary clinical history template
The patient record plus one sheet per consultation, on three A4 pages. Fill in the record once and the consultation sheet at every visit.
- Clinic, owner and patient details: species, breed, sex, neutered or spayed, date of birth, microchip, coat colour and weight.
- Vaccinations, parasite control, history and allergies.
- Consultation log to see the history at a glance.
- Consultation sheet with history, vital signs (temperature, HR, RR, mucous membranes, CRT and body condition), diagnostic tests, presumptive and definitive diagnosis, treatment, recheck, owner instructions and registration number.
Veterinary clinical report template
To give to the owner or file after a consultation. Two A4 pages, from the reason for the visit to the owner instructions.
- Clinic header, patient and owner details, date and vet.
- History, clinical examination with vital signs, and diagnostic tests.
- Diagnosis and procedures performed.
- Plan and recommendations: treatment with dose, route, frequency and duration, pending tests and recheck.
- Owner instructions, signature and registration number.
Veterinary referral report template
To refer a patient to another clinic, a hospital or a specialist. Two A4 pages.
- Referring clinic and vet, receiving clinic or specialist, date and urgency: routine, priority or urgent.
- Reason for referral and a specific clinical question.
- Brief history, findings and tests done, with a checklist for what you attach.
- Treatment given and response, and current medication.
- Owner consent to share their details and the patient's with the receiving clinic.
How to use them
- To adapt them, download the Word file: type your clinic's details once, add your logo and save it as your own template.
- If you are used to SOAP notes, the clinical report maps onto them: history is the S, examination and tests are the O, diagnosis is the A and the plan is the P.
- In the referral, write the specific clinical question. It lets the receiving vet focus on what you need.
- Before using the consent in the referral, check the wording with whoever handles data protection in your clinic.
If you would rather dictate than fill in forms, veterinary clinical records by voice explains the structure that comes out of the dictation and what happens to the audio.
Frequently asked questions
Are the templates free?
Yes. You download them without signing up and can use and adapt them in your clinic: change fields, add your logo or print them as often as you need.
How do I fill them in?
The PDF is meant to be printed and filled in by hand. The Word file (.docx) opens in Word, LibreOffice or Google Docs: type inside each box and add or remove fields. For the clinical history, print one consultation sheet per visit.
Do they work for any species?
Yes. The fields are general: species, breed, coat, weight and vital signs work for dogs, cats, exotics, horses or farm animals. For a specific species, adapt the Word file; for farm animals, for example, use the holding code and official identification instead of the microchip.
Published 17/10/2026. If a field is missing, write to info@artiprax.com.