Lifetime Pet Center of Williamsburg
Appointment Check-In Form
Date of Appointment
Please list the date of your appointment/ when it is scheduled.
Cell Phone Number
What is your pet being seen for today?
Exam with Dr. Miller- Sick/Injured
Exam with Dr. Miller- Wellness
Exam with Dr. Miller- Medical Progress/ Recheck
What current diet is your pet eating? (Brand, life stage, amount)
Is your pet allergic to anything? (Medications, food, vaccines, anesthesia, etc.) If yes, please list below.
Please list any medications or supplements your pet is currently taking below. Include dosage, frequency, and the last time each was given. (Also include preventatives for heartworm, and internal/ external parasites)
Has your pet shown any of the following symptoms recently? (Check all that apply)
Eating More/ Very Hungry
Not Drinking Water
Drinking A Lot of Water
Discharge from Eyes and/or Nose
Limping and/or Painful
Itching and/or Chewing
Shaking Head/ Scratching at Ears
Hair Loss/ Skin Red and/or Irritated
Lethargic/ Sleeping A Lot
Acting Off/ No Specific Symptoms
Here for recheck- symptoms have improved.
Here for recheck- symptoms have worsened.
Here for wellness- no problems or concerns.
How long have symptoms been present?
Please estimate when your pet started displaying the symptoms you have listed above.
Please include any other information below that you would like Dr. Miller to know for today's appointment.
Should be Empty: