Client Info/Pre-Visit Questionnaire

CLIENT INFORMATION SHEET
Date *

Month Day Year
Date
Client First Name: *
Client Last Name: *
Co-Owner/Spouse/Sig.Other:
Address: *
City: *
State: *
i.e. OK
Zip code: *
Home phone:
xxx-xxx-xxx
Cell phone: *
xxx-xxx-xxxx
Work phone:
xxx-xxx-xxxx
Preferred phone to contact? *
Co-Owner phone:
xxx-xxx-xxxx
E-mail: *
example@example.com
DL#: *
State: *
ie: OK
DOB *
MM-DD-YY

Patient Information

	Pet #1	Pet #2	Pet #3
Name
Breed
Age
Color
Sex (M/F)
Spayed/Neutered (Y/N)?
Previous illness/surgeries? (list)
Special diet/meds/allergies? (list)

How did you hear about Lakeview Pet Hospital?

Google Website Location/Sign Facebook Other
E-mail Communication: At LVPH, we use text & email to send important reminders about upcoming appointments, vaccinations, medications, and other necessary medical care reminders.

Opt-out of text & e-mail reminders (receive phone call reminders)
Photo Authorization: If the opportunity arises, may we showcase your pet on our website and social media? If you do not wish to give consent to Lakeview Pet Hospital to take and publish images of you with your pet or your pet(s) by themselves, please opt out below.

Opt-out: I prefer NOT to have photos taken and publicly shared
A technician or doctor will gladly prepare a written estimate upon request. ALL FEES ARE DUE AT THE TIME PROFESSIONAL SERVICES ARE RENDERED. We accept Cash, Check, and Visa/Mastercard/Discover. Any returned checks will be processed by the District Attorney’s Office. All hospitalized and boarded pets must be current on all vaccinations (verification required) and free from internal/external parasites. The signature below authorizes this level of preventative care and appropriate charges if needed.

I have read, understand, and assume responsibility for all information on client sheet and charges incurred in the care of my pet(s I also understand that these charges will be paid at time of release and that a deposit may be required for surgical treatments.
Signature of Responsible Party *

Clear
Printed Name *
WE LOOK FORWARD TO SERVING YOU AND YOUR PETS!!!
PRE-VISIT QUESTIONNAIRE
Pet’s Name: *
As Fear Free Certified Professionals, we want to make your pet’s veterinary experience as enjoyable and as stress-free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your and your pet’s preferences.
Does your pet show any reluctance to getting in the carrier or car? *

No Yes
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc) *
During travel to the veterinary hospital, does your pet do any of the following (select all that apply):

Eager & excited Reluctant Hide Drool Vomit Urine/BM Subdued Bark/Meow Whine Pant Tremble Pace
Does your pet prefer: *

Female veterinary professional Male veterinary professional It doesn't matter
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.

Getting in their carrier or the car Entering the veterinary hospital Other pets and/or people passing by while in reception/check-in Waiting with other people and animals in the waiting area Being approached by veterinary staff Getting on the scale for a weight Hearing the doorbell, overhead intercom, or phones ringing Sounds coming from the back areas of the practice Going into the exam room Being put up on the table for examination Having direct eye contact with the technician and/or veterinarian. Loud voices during examination Having a rectal temperature taken The use of instruments such as the stethoscope or otoscope (to look in the ears) Being taken out of the exam room for procedures
How would you describe your pet around other animals and people? *
Does your pet have any sensitive areas that s/he does not like to have touched by you or others? *
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did your pet react? *
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital): *
Does your pet like to play with toys? If so, what kinds? *
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience? *
Food allergies? Please let us know if you or your pet has food allergies and cannot have peanut butter, cheese, meat snacks etc. *
Should be Empty:

CLIENT INFORMATION SHEET

WE LOOK FORWARD TO SERVING YOU AND YOUR PETS!!!

PRE-VISIT QUESTIONNAIRE