Family Pets Vet Care Curbside General History Form
**This form should only be filled out if you already have an appointment scheduled. If you need to make an appointment, please call or text us at 479.521.7387 or click the "Request Appointment" link on our website.** Thank you for your understanding while we adapt to current recommendations in regards to limiting the spread of COVID-19. While we understand this process may not be ideal for everyone, we are taking the necessary precautions to be able to continue to treat our patients for as long as possible. Please complete this form to the best of your ability to help ensure accurate and efficient examination and treatment of your pet. When you arrive at the clinic at your scheduled time, we ask that you call and let us know you are here. Please have your pet on a secure collar/harness and leash or in a secure pet carrier before we come out to your car to collect your pet.
Client (human) Name
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First Name
Last Name
Client Email
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example@example.com
Primary Phone Number (Please enter the best number to reach you at on the day of your appointment. We will need to contact you before any treatments can be performed.)
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Area Code
Phone Number
Secondary Phone Number (because we will be needing to communicate with you by phone, an additional phone number is needed in case we cannot reach your primary number)
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Area Code
Phone Number
Emergency Phone Number
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Area Code
Phone Number
Appointment Date (if you haven't scheduled yet, please call or text us at 479.521.7387)
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Month
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Day
Year
Date
Pet Name
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Pet Species
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Dog
Cat
Other
Pet Breed
Pet's approximate age or DOB
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Is your pet spayed/neutered?
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Yes
No
I don't know
Is your pet current on their vaccines?
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Yes
No
I don't know
Has your pet been seen by another veterinarian? If so, when and where?
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Why are we seeing your pet today?
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General wellness or booster exam (with or without vaccines)
Rechecking a health concern that has been previously diagnosed
I have a new health concern (please describe below)
Other
If you have a health concern, please describe below. How long has it been going on? Is it improving, getting worse, staying the same? If you have no concerns, write "none."
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Where does your pet go (check all that apply and include places they may go within the next year)?
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Indoor only
Home and yard (in town)
Home and yard (wooded/rural)
Walks around neighborhood/town
Camping/Hunting/Hiking
Dog park
Groomer
Doggy daycare
Boarding facility
Training facility/puppy classes
Swimming in lakes and/or rivers
Travel out of the greater Northwest Arkansas area
Please list any prescription or OTC medications, diets, supplements, vitamins, heartworm/flea/tick meds, etc that your pet is currently taking or has taken in the last 60 days. Type "None" if they are not taking anything.
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Does your pet have any current/ongoing health issues and/or any allergies or sensitivities?
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Yes (describe below)
No
If yes, please list below.
What food are you feeding your pet (include kibble, canned, table scraps, homecooked, treats, etc)? List brands/flavors if at all possible. Also list things they tend to eat that they are not supposed to (trash, wildlife, toys, feces, etc).
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How often do you feed your pet?
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How much (quantity) do you feed your pet per feeding?
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Is your pet eating?
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Yes, they are eating normally.
Yes, and they are eating more than usual.
Yes, but not as much as usual.
Yes, but only small amount and/or with coaxing.
No, they are not wanting to eat.
Other
Is your pet drinking water?
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Yes, they are drinking their normal amount.
Yes, they are drinking more than usual.
Yes, but not as much as usual.
Yes, but only small amount and/or with coaxing.
No, they are not drinking.
Other
Is your pet vomiting?
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Yes, they are vomiting or have recently.
No, there has been no recent vomiting.
If yes, describe how often they are vomiting, what it looks like, and when it occurs (after eating, drinking, exercising, all the time, etc).
Describe your pet's recent urination habits (select all that apply).
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Normal amounts and frequency.
Urinating less often.
Urinating more often.
Urinating in new/inappropriate places.
Urine looks/smells abnormal.
Other
If abnormal, please provide any additional information.
Describe your pet's recent bowel movements (select all that apply).
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Normal appearance and frequency.
Loose
Watery
Bloody
Dark
Tarry
Mucoid (mucus)
Less frequent than usual
My pet is not producing bowel movements.
Does your pet seem painful?
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Yes
No
Unsure
If yes or unsure, describe below.
Is your pet coughing and/or sneezing (check all that apply)?
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No
Coughing
Sneezing
Is there any addition information that would be helpful (more details about answers above, behavioral concerns, helpful hints on handling your pet, particular triggers your pet may have, etc)?
If your pet has been seen at another facility that we do not already have records from, please provide the name(s) and locations of those clinics so that we can request their records. This will ensure that we have all the information needed to appropriately care for your pet.
In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of your pet's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Although we may not anticipate any issues, because you will not be onsite for any/all treatment, please indicate your wishes below in the event of any cardiac and/or respiratory arrest while your pet is with us today.
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I agree to CPR being performed in case of arrest.
I elect a “Do Not Resuscitate” status in case of arrest .
Fine Print: I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. By entering my name below, I certify that I am over eighteen years of age. I authorize and direct the veterinarian and designated staff of Family Pets Vet Care to receive, treat, medicate, and perform diagnostic and/or therapeutic procedures as discussed and provided in the estimate. If no estimate has been provided, I authorize a comprehensive exam (cost is $55) to be performed in order to generate an estimate. The purpose of the hospitalization and the proposed treatment plan have been clearly explained to me. I understand that no guarantee of successful treatment outcome can be given and that the patient's condition may improve or decline during the period of hospitalization despite appropriate medical care and monitoring. I understand that unexpected reactions to medications can occur. If I have any questions about the potential risks, I have discussed them with the staff before hospitalizing my pet. If further care is needed after business hours (Monday-Friday 8:00am-5:30pm) or on holidays, I understand that transfer of care to Emergency Pet Care is recommended. Patient transport to and from the emergency clinic as well as any additional cost incurred during the stay are my responsibility. In the event that transfer to the emergency clinic is not a possibility, I understand that the patient will only receive intermittent monitoring and that unexpected and serious complications may develop during this period. I agree to pay in full at time of service for all services performed, including those deemed necessary for medical/surgical complications or otherwise unexpected circumstances. I have read and understand this authorization and hereby accept and agree to the terms of the consent for hospitalization and/or treatment.
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Type your full name to agree to the above statements.
Submit
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