Appointment Questionnaire
Name
First Name
Last Name
Pets Name
Phone Number
Reason for visit
Wellness Exam
Illness
Injury
Other
Please check all that apply to your pet
Not eating
Decrease in appetite
Increase in appetite
Not drinking
Increase thirst
Weight loss
Weight gain
Vomiting
Diarrhea
Skin masses/lumps
Scooting
Shaking head
Urination issues
Limping/lameness
Stiffness
Bad breath
Drooling
Chewing or licking
Scratching
Hair loss
Coughing/sneezing
Gagging
Squinting eyes
Lacerations
Open wounds
Lethargic
Change in activity level
Excessive panting
Labored breathing
Other
Please check any preventative care services that you would like for your pet to receive
Heart worm test - dog only
Early Detection Panel (includes heartworm test for dogs)
Add-on urine testing with Early Detection Panel
Recheck bloodwork for medications
Intestinal parasite screening (fecal floatation)
Microchip
Anal glad expression
Clean ears
Toe nail trim
If you checked yes to parasite screening, did you bring a stool sample?
Please dispense
Flea and tick medication for cats
Flea and tick medication for dogs
Oral heartworm prevention for dogs
Injectable heartworm prevention for dogs (Proheart)
If dispensing flea or heartworm medication, how many doses would you like to purchase?
Please check any vaccines that you would like your pet to receive today
FVRCP - cat
DHPP (distemper, parvo) - dog
Bordetella - dog
Lepto - dog
Rabies - dog
Rabies - cat
Canine influenza - dog
Is your pet taking any medications?
Yes
No
If yes, please list medications AND the dosing
Has your pet had any adverse reactions to any medications or vaccines in the past?
Yes
No
If yes, please describe
What food do you feed your pet? How much and how often?
Do you feed your pet treats?
Yes
No
Please enter any additional information you'd like the doctor to know
Does your pet already have an appointment scheduled?
*
Yes
No
If so, when?
Schedule An Appointment
Your Name
First Name
Last Name
Pet's Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Preferred Date
-
Month
-
Day
Year
Date
Preferred Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Reason for Visit
Submit
Should be Empty: