Patient History Form
Phone number to reach you at time of appointment
Has your address/phone number changed?
Yes(if yes please add below)
Please enter new address/phone number(s) below
Date of Appointment
What is the primary reason for your visit today?
When did the symptoms start?
What is your pet's current diet?
Would you like an estimate for today's appointment?
Please list current medications and supplements:
Is your pet up to date on vaccinations?
Is your pet experiencing any of the following?
Decrease in appetite
Decrease in water intake
Blood in stool
Increased frequency of urination
Scratching ears or shaking head
Discharge from eyes
Discharge from nose
Any allergies to food or medications?
Last dose of heartworm and flea/tick prevention? Please include brand (ie Heartgard, Nexgard)
Do you need any Heartworm preventative, Flea/tick preventative or medication or food refilled? If so, how much?
Do you have any concerns about getting your pet to our office or concerns about your pet's stress level during their visit?
If there is anything else you would like us to know, please include below:
COVID 19 QUESTIONAIRE
Have you or a family member tested positive for Covid-19 in the last 14 days?
Are you or any member of your household experiencing any of the following symptoms?
Fever of higher than 100.4, Loss of smell or taste, Difficulty breathing, Cough,Sore throat, Diarrhea, Vomiting, or any other symptom(s) of Covid 19?
If you have answered yes to any of these questions we ask that you postpone your visit at least 14 days from the start of your symptoms or have a non household member who does not have any Covid-19 symptoms bring your pet. Thank you for your understanding.
Should be Empty: