Patient History Form

COVID 19 GUIDELINES

In an effort to adhere to social distancing guidlines, we are not allowing clients to come in to our clinic. When you arrive, your pet will be brought in while you wait outside. ALL communication with the doctor will occur over the phone during your visit. Payment will be collected over the phone at the conclusion of your appointment.

Please have a cell phone available during your appointment. Please put the best number top reach you during the visit.
Please arrive 5-10 minutes prior to your appointment
Please call the clinic at 707-448-6275 when you arrive
You will be instructed by the technician when it is time to meet at the front door.
Please have your pet on a leash or carrier
Please wear a mask
pleasE fill this out prior to your appointment

Owners name

First NameLast Name

Pets name

Cell Phone number

Area CodePhone Number

Date

Please describe the reason for your appointment such as: vaccines, ear infection, vomiting, sick, limping. Please answer following questions below regardless of why your pet is here

Has your pet had any coughing?

Is your pet scratching, chewing or licking?

Has your pet had any sneezing?

Does your pet have any nasal discharge?

Is your pet defecting normally?

Has your pet had diarrhea?

Is your pet vomiting?

If yes to any above questions, please describe and how long

Have you noticed a change in your pets drinking or urination?

If yes , describe in detail and indicate how long

Is your pet scratching, licking or chewing?

What do you feed your pet? (include treats, snacks, etc.)

Brand, wet/ Dry etc.)

Any recent changes to their diet/food?

If yes, when and what did you change?

Is your pet lethargic? (less active, acting dumpy or sick)

If yes, how long?

For cats:

Are there any new lumps or bumps you have found?

Have you noticed your pet having difficulty getting around, standing from lying down, not wanting to jump, difficulty with stairs, limping etc?

If you answered yes to above questions please describe and how long

If your pet is on Heartworm preventative please write name:

If your pet is on flea/tick preventative please write name

If you need refills of any medication, or preventative please list:

Please list all medications your pet is on, how much and how often are you giving the medication and when the last does was (if applicable)

Please list any additional information not listed above that you will feel will be helpful treating your pet today.