River Road - Patient Consult Questionnaire

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Patient Consult Questionnaire* This field is required.-
- **Pet's Name**
- **Your Full Name**
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- **Your phone number**
- **Your email address**
- **Reason for appointment?**
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*How is your pet's...*
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Please Select
Normal
Abnormal
- **Appetite?**
**If abnormal, please elaborate:**
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Please Select
Normal
Abnormal
- **Water intake?**
**If abnormal, please elaborate.
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Please Select
Normal
Abnormal
- **Urination?**
**If abnormal, please elaborate.**
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Please Select
Normal
Abnormal
- **Bowel Movements?**
**If abnormal, please elaborate.**
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Please Select
Please Select
Yes
No
- **Has your pet been vomiting?**
**If yes, please provide detail.**
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Please Select
Yes
No
- **Any recent change in activity/energy levels?**
**If yes, please provide detail.**
- **Has your pet been scratching? If yes, please provide detail.**
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* This field is required.
- **Is your pet indoor, outdoor, or both?**
- **To what other animals is your pet exposed?**
- **Are there any behavioral issues you would like to discuss?**
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- **What heartworm prevention is your pet currently taking?*** This field is required.
**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
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- **What flea and tick prevention is your pet currently taking?*** This field is required.
**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
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- **What food(s) does your pet eat, and how much/how often are they fed? Any treats?*** This field is required.
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- **What medications and/or supplements is your pet taking? Do you need refills?*** This field is required.Please provide prescription strengths and quantity/frequency given if possible.
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**Labwork Consent?:** We conduct annual wellness lab work as part of our commitment to maintaining your pet's health. This proactive approach helps us detect any underlying health issues early, ensuring timely and effective intervention. While this is a standard part of our wellness care, it is optional. Your consent allows us to proceed with these important tests. ($120-$170) Consent? (Yes/No)
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- **Are you a member of -or interested in learning more about- RRVH's Wellness Plans?**We're excited to offer you the benefit of Snout Wellness Plans. Enjoy everything your veterinarian recommends for your pet's wellness health plus *Unlimited FREE Exams*! With payments spread out over time, this is the ultimate convenience in pet wellness. Sign-up is easy: Visit www.
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- **Are there any other general health concerns you would like to discuss?*** This field is required.
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