Canine Medical Problem History

Canine History - Medical Problem
Appointment Date*

MonthDayYear
Date
Owner's Name*

First NameLast Name
Pet Name*
Phone Number for contact during visit (via call or text)

Area CodePhone Number
Today's Concern*
How long has this been going on*
Heartworm prevention -which product?*
Diet & appetite*
Heartworm Prevention -last given date?

MonthDayYear
Date
Flea & Tick Prevention - which product?*
Flea & Tick Prevention - last given date?

MonthDayYear
Date
Change in energy?*
Any other medications and if so what?*
Change in thirst/urination?*
Coughing, Sneezing, Vomiting, or Diarrhea?*
Recent signs of fleas or other parasites?*
If last preventive care (vaccines, parasite testing) was not done at Log Cabin, where & approx when or up to date, if known?*
clinic/date if known or overdue if >1year
Other info you would like us to know*
How will you be paying today? (credit/debit, cash, check or care credit)*
Please be aware, we are operating curbside only at this time, meaning owners are not coming into the building with pets. Please see www.logcabinvet.net/curbside-service for more information.
Have you or anyone in your household had COVID19 or symptoms of illness (cough, fever, loss of taste/smell, sore throat, chills, difficulty breathing...) within the past 2 weeks?*

YesNoPrefer not to answer
Should be Empty: