Early Check In Form
This questionnaire is designed to reduce your wait times for your appointment while we provide curbside care during the global pandemic. Ideally, submitting the completed form prior to your appointment will allow us to expedite care during your appointment but the form can be filled out at the time of your appointment as well. Your veterinarian will call to clarify any additional details not covered on the form after examining your pet. Thank you for your patience and cooperation during these unprecedented times.
Date of Your Appointment
-
Month
-
Day
Year
Date
Name:
*
First Name
Last Name
Phone Number to Contact You During Your Curbside Appointment:
*
Pet's Name:
*
Name
Vehicle Make/Model:
Primary reason for your visit:
Is your pet experiencing any coughing, sneezing, vomiting or diarrhea?
Coughing
Sneezing
Vomiting
Diarrhea
None of the above
If experiencing any of the above, please describe the duration, frequency, and appearance for each:
Any known illnesses since your pet's last vet visit?
Any Known Allergies?
Change in water intake:
Increase
Decrease
Normal
Change in urination:
Increase
Decrease
Normal
Change in appetite:
Increase
Decrease
Normal
Change in weight:
Increase
Decrease
Normal
If your pet is on medication, please list them out and include the dose, frequency, and date started:
Any tick/flea preventative?:
Yes
No
Are vaccines up to date?:
Yes
No
What are you currently feeding your pet? Please include name, quantity, and frequency of feeding:
Do they get any additional treats or table scraps?
Does your pet have any other illnesses? Or is there anything in particular you wanted the doctor to take a look at?
Itching, scratching, lumps, etc.
Are there any additional services you would like performed during your visit today? (We will call you for details if needed):
Nail Trim
Express Anal Glands
Update Vaccines
Heart worm Test
Parasite Prevention Refills
Medication Refills
I decline any preventive services
If there are any vaccine/medical records/pictures that need to be updated or recorded, you can attach them here.
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