Patient Health Summary

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Welcome

Welcome

Hi there, please fill out and submit this form.

1
Are you, or someone you've been in contact with, experiencing any sore throat, fever, or any type of respiratory distress including coughing?
YESNO
2
In the past 14 days, have you had any known contact with someone who was confirmed by a medical practitioner to be infected with the Covid-19 virus?
YESNO
3
In the past 14 days, have you been on a cruise or traveled to a country with widespread transmission of Covid-19?
YESNO
4
If you selected YES, please call our office on how we should proceed and so we may best prepare for arrival.

517-669-2381
5
Your First Name
6
Your Last Name
7
Have you been here before?
YESNO
8
Your Phone Number
Area Code
Phone Number
9
Your Pet's Name:
10
Please choose species
Canine
Feline
11
Has your pet been here before?
YESNO
12
Date
Year
Month
Day
13
What time is your appointment?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
14
Please state the reason we are seeing your pet today! Be as detailed as possible:
Huge
Large
Normal
Small
Ok
Ok
15
Do you need refills on any medications?
YESNO
16
If you DO need refills, what are you looking for? please type N/A if this doesn't apply to you today.
17
What type &/or brand of food does your pet eat?
18
What is the nature of your pet's appetite?
Normal
Increased
Decreased
19
What is the nature of your pet's water consumption?
Normal
Increased
Deccreased
20
Is your pet coughing?
YESNO
21
Is your pet sneezing?
YESNO
22
Is your pet vomiting?
YESNO
23
Is your pet experiencing diarrhea?
YESNO
24
Is your pet having any issues urinating?
YESNO
25
Is there anything else we should know about your appointment today? Please type N/A if this is not applicable.
Huge
Large
Normal
Small
Ok
Ok
26
When you arrive, please have your cat in a carrier that is securely put together. All dogs must be on a leash. We will plan to have you step out of the car and wait to remove your leash until we have OURS on. We will let you know when it's time to come out so you're not stuck standing outdoors.
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