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Patient Health Summary for Appointment - Churchland Animal Clinic 8/2020
1
COVID Screening Questions
1. Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? 2. Do you live in the same household with, or have you had close contact* with someone who in the past 14 days has been in isolation for COVID-19 or had a test confirming they have the virus? 3. Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason? • Fever, Chills, or Repeated Shaking/Shivering • Cough • Sore Throat • Shortness of Breath, Difficulty Breathing • Feeling Unusually Weak or Fatigued • Loss of Taste or Smell • Muscle pain • Headache • Runny or congested nose • Diarrhea Please choose an option below for your answer and describe any necessary details.
Please Select
I answer NO to all 3 screening questions.
I answer YES to one or more of the 3 screening questions.
Please Select
Please Select
I answer NO to all 3 screening questions.
I answer YES to one or more of the 3 screening questions.
Please choose
Type any additional information
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2
Your Full Name
First Name
Last Name
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3
Best phone # to reach you while you wait in the parking lot during appointment
The Veterinarian and assistant will use this number to communicate with you through the appointment.
Area Code
Phone Number
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4
Pet's Name
Patient being seen for today's appointment
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5
Does your pet have any of the following symptoms?
Coughing?
Vomiting?
Sneezing?
Diarrhea?
Lameness?
Itching?
Lumps?
Bumps?
Hairballs?
None of the Above
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6
Describe your Concerns
Please be as detailed as possible.
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7
Diet
What brand of food does your pet eat? How much? How often?
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8
Medications and Refill Request
Please list all current medications including heartworm and flea/tick preventions. Refills needed?
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9
Please type your name below to acknowledge and agree, that unless approved by CAC staff you will remain in the CAC parking lot for the entire length of your pets visit. If you leave without approval a $30 boarding fee will apply.
*
This field is required.
Type your full name
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10
In the event consent is needed for diagnostic procedures and/or treatments for my pet at today's appointment, I authorize to give verbal consent following the explanation and review of provided documents in place of my signature.
YES
NO
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11
Signature
Clear
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Patient Health Summary for Appointment
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