Ottawa Animal Hospital - West Curbside Appointment

Curbside History Form

Please have this form complete before coming to the hospital. Your pet will be brought into the hospital by a team member, the doctor will do an exam, and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment for services will be curbside as well and expected after the visit is complete.
Due to the COVID-19 prevalence, we want to ensure your safety and that of our team. Please answer yes/no to these questions:
*Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.
Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough or difficulty breathing? *

Yes No
Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19? *

Yes No
Your Name *

First Name Last Name
Pet's Name *
Cell Phone Number *

Area Code Phone Number
Appointment Date *

Month Day Year
Date
Appointment Time *

: Hour Minutes AM/PM Option
Are you a new client? *

Yes No
Your Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Other Authorized Person(s) on Account:
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
How did you hear about us? *
If from a friend, please share with us so we know who to thank!
Pet Type *
Breed (if applicable)
Estimate age or date of birth *
Color(s)/Marking(s)
Pet's gender *

Male Female
Is your pet spayed/neutered? *

Yes No
How long have you owned your pet? *
When was the last time your pet received a vaccine? *
Last veterinarian who provided services for your pet? *
If there any previous medical problems or allergies of which we should be aware, please list and describe them here:
If your pet is currently on any medications, please list what type(s), and frequency here (including heartworm & flea medication):
What brand of pet food do you currently feed? *
Photo Consent: We love to take photos of our patients for educational purposes, marketing, social media, our website and medical charting reasons. No personal information will be used without your permission. Do you consent to allowing us to take and/or use photos of your pet for the above described purposes? *

Yes No
Due to the nature of the services rendered in this office, full payment is required when services are rendered. Please indicate below your choice of payment. *

Cash Personal Check Visa/Mastercard/Discover Care Credit Scratchpay
Has your pet been coughing? *

Yes No
Has your pet been sneezing? *

Yes No
Does your pet have nasal discharge? *

Yes No
If so, what color and which nostril(s)?
Has your pet been vomiting? *

Yes No
If your pet has been vomiting, when what the last time and describe the vomit.
Has your pet had diarrhea? *

Yes No
Does your pet's stool look normal color? *

Yes No
If no, is it black or bloody? Describe.
Has your pet been drinking more? *

Yes No
Has your pet been urinating more? *

Yes No
If so, what's the color and the amount?
Has your pet's appetite changed? *

Yes No
If so, describe how.
Any change in diet? *

Yes No
If yes, when and what did you change in their diet?
Is your pet lethargic? *

Yes No
If yes, how long have they been lethargic?
Is your pet here because it is limping? If so, which leg and how long? *

Yes No
If yes, how long has your pet been limping, and which leg for how long?
Please list all medications your pet is on and when they were last given (including supplements). *
Is your pet acting painful? *

Yes No
If yes, what was your pet doing when this occurred?
Does your pet have problems with one or both of their eyes? *

Yes No
If yes, which eye? Describe any drainage or symptoms.
Does your pet have problems with one or both of its ears? *

Yes No
If yes, which ear? Describe any discharge or symptoms.
Is your pet experiencing any unusual itching? *

Yes No
If yes, where is your pet scratching? Please describe.
Do you have concerns with your pet’s teeth? *

Yes No
If yes, please describe.
For an additional fee, would you like your pet’s nails trimmed while here? *

Yes No
If there are if any concerns with the nails, please describe.
Would you like your pet’s anal glands expressed? *

Yes No
Is your pet scooting or licking it's hind end? *

Yes No
Does your pet have any new lumps or bumps you have found? *

Yes No
If yes, where are they and how long have they been present?
Please use this comment section to include any questions or concerns you have. Please also include any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.
If you are scheduled for a routine, annual exam, we recommend yearly blood work and intestinal parasite screening twice a year, and appropriate vaccinations due updated.

Please have a mask on when the technician comes to your vehicle.

Please have your pet on a leash or in a carrier before we come to the car.
When you park, please call the office to let us know you have arrived. To help assist us, please let us know the color, make, and model of your car.
(White Jeep Wrangler)
Would you prefer to pay for your services/product today via a secure link sent via text or email directly to your phone or would you prefer to pay with a team member over the phone? *

I prefer to pay via secure link that will be sent via text or e-mail to my phone I prefer to pay with a team member over the phone
I authorize curbside service and care of my pet by the veterinarians and staff of Ottawa Animal Hospital - West. I understand this may involve my pet being accompanied by a staff member during their visit,rather than myself. I understand that staff members will be handling my pet;they may be approaching and/or partially entering my vehicle or meeting me at the clinic door. Further medical authorization of recommended treatment(s) will be done via phone communication; I consent to over the phone financial and treatment authorization.
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Curbside History Form