Appointment Check-in Form
Welcome to The Animal Hospital at Lake Brandt, please complete the form below to check-in for your appointment.
Client Name
First Name
Last Name
Pet Name
Date
-
Month
-
Day
Year
Date
Appointment Time
Phone Number where the doctor can reach you to review your pet's treatment plan.
Please enter a valid phone number.
Format: (000) 000-0000.
Is this a cell phone number?
YES
NO
Make and Model of Car
Is this appointment:
Curbside
In-person
Drop-off
Is your pet:
Indoor Only
Indoor/outdoor
Outdoor Only
What foods or treats do you currently feed? Please indicate how much and how ofter.
Have there been any recent dietary changes? Including new treats, food change, increase/decrease in eating.
YES
NO
If you indicated yes above regarding a recent dietary change, please explain here:
Do you feed your pet "human food"?
YES
NO
Drinking:
Normal
More than normal
Less than normal
Not al all
Urinating:
Normal
More than normal
Less than normal
Not al all
Blood noticed
Please list any current medications and/or supplements:
Current Heartworm Prevention:
Current Flea/Tick Prevention:
Has your pet had any allergic reactions in the past?
YES
NO
If yes to allergic reactions, please explain here:
Has there been any coughing or sneezing?
YES
NO
If yes to coughing and sneezing, please explain here:
Has there been any vomiting, diarrhea or constipation?
YES
NO
If yes to vomiting, diarrhea or constipation, please explain here:
Please list any concerns at this time:
Submit
Should be Empty: