Curbside Exam History Form

Please have this form completed and returned before coming to the hospital. Please also have the cell phone whose number is listed here available while you are here for your appointment. A team member will bring your cat into the hospital, the doctor will do the exam while you wait (10 to 15 minutes) and then will call you to go over the exam and discuss next steps. Payment of services will be curbside and expected after the visit is complete.

Curbside appointment
- Please arrive 5 minutes before your appointment time
- If your cat is scheduled for their wellness exam we recommend updating any vaccines that are due. If your cat is scheduled for a mature wellness exam and it has been a year since their last labs we recommend our Feline Mature Package.
Notify us of your arrival
- Please check in via the QR code on the parking sign, clicking the "Check In" link on our website, OR by texting us at 650-359-5770
- If you *call* and we don't answer, please DO NOT leave a voicemail. Please call back or try one of the methods above
Park
- Please let us know where you have parked and the make, model & color of your car.
Cat Prepared
- Please have your cat secured in their carrier before we come to the car.

Owner's Name (First and last) *

Please enter the full name of the main client on the account

Patient's / Cat's Name *

Please fill out one form PER CAT if you are bringing multiple patients to see us.

Cell Phone *

Please provide the best phone number for us to reach you at while you wait during your appointment

Appointment Date *

Please enter your APPOINTMENT date, not the date you're filling this out

In TEN (10) words or LESS (more will be cut off) note the reason your cat is being examined today. You will have more room at the bottom of the form to elaborate *

This is a small space, you will have more room at the bottom of this form to elaborate

Is your cat strictly indoors? *

Yes No

If no, please describe their outdoor contact (covered porch, supervised, unsupervised, etc.) *

What is your cat eating? Please note the name/brand, if it is canned, dry or both, and how much they eat per meal & day. *

Has there been any change in diet (including decreasing to assist in weight loss)? *

Yes No

If yes, when and what did you change? *

Please be as descriptive as possible

Is your cat on flea/tick control? *

Yes No

If yes, please note what medication you are using and when it was last applied. *

Please list all medications, including over the counter supplements, your cat is on and when they were last given, including date and time. *

Please don't just note "yesterday" or similar as this form is not dated.

Has your cat had any coughing? *

Yes No

If yes, please explain, including duration and frequency. *

Has your cat had any sneezing or nasal discharge? *

Yes No

If yes, please explain, including duration, frequency, and any color to the discharge. *

Has your cat been vomiting? *

Yes No

If yes, please describe the vomit, including frequency, duration, and when it last occurred *

Has your cat had diarrhea or abnormal stool? *

Yes No

If yes, please describe the consistency of the stool, duration of the issue, and any other changes. *

Has your cat been drinking more or less? *

Yes, More Yes, Less No

If yes, is the change in frequency, quantity, or both? *

Frequency Quantity Both

How long have you noticed the change? *

Has your cat been urinating more or less? *

Yes, More Yes, Less No

If yes, is the increase in frequency, quantity, or both? *

Frequency Quantity Both

How long have you noticed the change? *

Has your cat’s appetite changed *

Yes No

If yes, please describe the change *

Increase, decrease, how long, etc.

Is your cat lethargic (not active)? *

Yes No

If yes, how long has it been going on? *

Have there been any changes in mobility, such as changes in how they jump or go up and down steps? *

Yes No

If yes, please describe. *

Please be as detailed as possibly including how long you've noticed the change

Does your cat have a problem with one or both of their eyes? *

Yes No

If yes, please note which eye *

Right Left Both

Please describe any drainage or symptoms and how long it has been going on. *

Please include how long the issue has been going on

Does your cat have a problem with one or both of their ears? *

Yes No

If yes, please note which ear *

Right Left Both

Please describe any discharge or symptoms and how long it has been going on. *

Do you have a concern with your cat’s teeth? *

Yes No

If yes, please explain/describe *

Please include how long the issue has been going on

Would you like your cat’s nails trimmed while here? Note this is an additional cost. *

Yes No

Please note if you have any concerns with the nails. *

If your cat is due for vaccines or lab work, do you preauthorize us to perform these services? This means that we can go forward with vaccines or labs before speaking with you on the phone. If you need to be contacted first, please mark NO *

Yes No

Please note any restrictions to the above authorization *

We will provide a treatment plan on request

Are there any other things you would like done while your cat is here *

Yes No

If yes, please list in the space provided *

Are there any other concerns you have about your cat that were not covered above? *

Yes No

If yes, please list in the space provided. *