Appointment History Form
PLEASE NOTE: This form is to collect details for upcoming appointments that are already scheduled. If you are looking to book an appointment, please reach out to us directly.
Phone: 416-966-1830 Email: wellesleyanimalhospital@gmail.com
Your Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Pet's Name
*
Date of appointment
*
-
Month
-
Day
Year
Date
Time of appointment
Hour Minutes
AM
PM
AM/PM Option
If this is your first visit with us, please provide any previous medical records. If you do not have them, please provide the name of your previous vet clinic . If your pet is from a breeder, please bring any record you have.
*
Please also include the name of the person who will be answering the call if more than one owner is listed.
What is the primary reason for your pet's visit?
*
If applicable, when did you first notice the symptom(s) described above?
If applicable, how frequently is each symptom occurring?
Any concerns with appetite and/or energy?
*
Yes
No
If yes, please describe:
Any vomiting or diarrhea?
*
Yes
No
If yes, please describe:
Any coughing or sneezing?
*
Yes
No
What type of food does your pet eat and how much? (Please include the brand name and variety if possible)
*
Would you like to run a fecal test looking for intestinal parasites? This test is recommended once yearly as part of a regular preventive health plan and is $97 plus tax.
*
Yes
No
Would like to discuss
DOGS ONLY. Has your dog had a heartworm & tick-borne disease test (4DX test) in the past twelve months?
Yes
No
Unsure
Are you interested in taking home some parasite prevention ( flea, tick, and internal parasite prevention) for your pet today? Parasite prevention is recommended as part of a comprehensive preventive health plan.
*
Yes
No
Would like to discuss
Would you like your pets nails trimmed at this visit? ($23.70 plus tax)
*
Yes
No
Would like to discuss
Is your pet scooting? If so, are you interested in having an anal gland expression performed at this visit? ($31 plus tax)
*
Yes
No
Would like to discuss
Do you have any other concerns you'd like addressed or services performed at your pet's upcoming appointment?:
*
Submit
Should be Empty: