Patient Information Form

Have you noticed any coughing or sneezing:*

CoughingSneezingNone

Have you noticed any sneezing, vomiting or diarrhea?*

SneezingVomitingDiarrheaNone

If coughing and/or sneezing, how long?

If vomiting, how long and what does it look like?

If diarrhea, how long?

Is there any of the following in the diarrhea:

BloodMucusAccidents in the house

Has there been any recent changes in your pet's bowel movements?*

Examples: Straining, very hard stools, dark/black stools, less frequent, more frequent.

Has there been any recent changes in your pet's urinary habits?*

Examples: Straining, accidents, color/bloody, odors, less frequent, more frequent.

Have you noticed a change in your pet's willingness to play or exercise?*

YesNo

Have you noticed any increased drinking, loss of consciousness, seizure activity, bruising or bleeding?*

Has your pet lost or gained weight?*

GainedLostMy pet has not lost or gained weight

Does your pet travel outside of Southeastern Michigan?*

Other comments:

Please list the specific goals you have for the consultation:

Please list any questions you would like answered during the consultation:

Thank you for taking the time to fill out your forms. A second email has also been sent. Please be sure to fill out both, as this helps us to better serve you and your pet. We look forward to seeing you.

Our physical address is:

8560 N. Canton Center Rd.

Canton, MI 48187

we are located inside Canton Professional Park in the back of the complex on the right side