Caring Hands Vet - Appointment Questions

1

Reason for today's Visit* This field is required.

2

Which would you prefer for you pet’s exam today?* This field is required.

Curbside

In-person

3

Client & Patient Information

First Name

Last Name

Best number for today’s appointment

Email

Pet's Name

Who is your Pet Insurance provider?

4

Is your pet on any medications, vitamins, probiotics or other supplements?* This field is required.

Yes

No

5

Please list all medications and supplements (name, dosage, frequency)* This field is required.

6

Is it OK for us to give your pet treats while visiting us?* This field is required.

YESNO

7

Sometimes we may give peanut butter as a treat. Does anyone have peanut allergies in your household?* This field is required.

YESNO

8

Have you noticed any change in any of the following?* This field is required.Please select all that apply

Appetite

Activity Level

Urination

Defecation

Water Intake

None

9

When did you first notice the change in your pet's appetite?* This field is required.

10

When did you first notice the change in your pet's activity level?* This field is required.

11

When did you first notice the change in your pet's unration?* This field is required.Please describe this change in frequency, amount, color, etc.

When did you notice this change?

Please describe

12

When did you first notice the change if your pet's defecation?* This field is required.Please describe this change in frequency, consistency, etc.

When did you notice this change?

Please describe

13

When did you first notice the change in your pet's water intake?* This field is required.

15

If your pet is vomiting* This field is required.

16

If your pet has diarrhea* This field is required.

17

If your pet is coughing

18

If your pet is sneezing* This field is required.

When did the sneezing begin?

Please describe the frequency

19

Please describe your pet's lumps or bumps* This field is required.

20

Please describe your pet's skin irritation or itching* This field is required.

21

Is your pet on Heartworm or Flea & Tick prevention?* This field is required.Please select all that apply

Heartworm Prevention

Flea & Tick Prevention

None

22

Heartworm Prevention

23

Flea & Tick Prevention

24

Pet's Diet* This field is required.

25

COVID-19 Screening* This field is required.Are you or anyone in your household currently diagnosed with, being tested for, or exhibiting any symptoms of COVID-19?

Yes

No