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
Phone Number to Contact You During Your Curbside Appointment:
Primary reason for your visit:
Is your pet experiencing any coughing, sneezing, vomiting or diarrhea?
None of the above
If experiencing any of the above, please describe the duration, frequency, and appearance for each:
Change in water intake:
Change in urination:
Change in appetite:
Change in weight:
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.
If your pet is on medication, please list them out and include the dose, frequency, and date started:
What are you currently feeding your pet? Please include name, quantity, and frequency of feeding:
Do they get any additional treats or table scraps?
Are there any additional services you would like performed during your visit today? (We will call you for details if needed):
Express Anal Glands
Heart worm Test
Parasite Prevention 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.
Should be Empty:
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