Dallas Veterinary Clinic - Appointment Check-in Form Old

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Appointment Check In

During this time, we are asking all clients to fill this out prior to their pet’s appointment.

Please note: In order to schedule an appointment, please call our team or the Appointment link below. Please schedule your appointment prior to completing the check-in form below.

Appointment
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I am in this vehicle* This field is required.
(please list model & color)
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Best Phone number for today's appointment* This field is required.(the Veterinarian and technician will use this number to communicate with you through the appointment.)
Area Code
Phone Number
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* This field is required.
Email
Patient's Name
Canine
Feline
Patient's Species
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Owner's Name* This field is required.
First Name
Last Name
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Appointment Date/Time* This field is required.
Date
Month
Day
Year
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2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
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Primary Reason for Appointment / Concern (please be as detailed as possible)* This field is required.
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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.
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Does your pet show any reluctance to getting in the carrier or car?* This field is required.
Yes
No
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How and where does your pet travel in the car? (carrier, seatbelt, loose, etc)* This field is required.
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During travel to the veterinary hospital, does your pet do any of the following* This field is required.
Eager & excited
Reluctant
Hide
Drool
Vomit
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Other
None
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Does your pet prefer* This field is required.
Female veterinary professional
Male veterinary professional
It Doesn't Matter
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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.* This field is required.
Getting in their carrier or the car
Going into the exam room
Entering the veterinary hospital
Being put up on the table for examination
Other pets and /or people passing by while in reception/check-in
Having direct eye contact with the technician and/or veterinarian
Waiting with other people and animals in the waiting area
Loud voices during examination
Being approached by veterinary staff
Having a rectal temperature taken
Getting on the scale for a weight
The use of instruments such as the stethoscope or otoscope(to look in the ears)
Hearing the doorbell, overhead intercom. or phones ringing
Being taken out of the exam room for procedures
Sounds coming from the back areas of the practice
None
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How would you describe your pet around other animals and people?* This field is required.
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Does your pet have any sensitive areas that s/he does not like to have touched by you or others?* This field is required.
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What are your pet's favorite treats? (Please bring some to your next visit to our hospital)* This field is required.
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Does your pet like to play with toys? If so, what kinds?* This field is required.
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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 reach?* This field is required.
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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?* This field is required.
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Patient's Energy Level* This field is required.
Normal
Increased
Decreased
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What brands of Parasite Preventative do you use?* This field is required.
Heartworm Preventative
Flea & Tick Preventative
Yes - Both Heartworm & Flea/Tick
Yes - Heartworm Only
Yes - Flea/Tick Only
No Refills needed
Do you need a refill?
Yes
No
Have you missed any heartworm doses?
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Would you like your pet to receive Proheart 6 injection (heartworm protection which lasts 6 months) when the next administering is due?* This field is required.
Yes
No
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If a heartworm test is due soon (we can take care of it today to save another trip), do you want us to do a full internal organ health screening ($149)?* This field is required.
Yes
No
Heartworm test is not due soon
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If any vaccines (except boosters that need to be spaced 3-4 wks apart) are coming up due in next 30 days, do you want us to go ahead and update those today if the doctor thinks it's okay to do so?* This field is required.
Yes
No
No vaccines coming up
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List Medications your pet is currently taking* This field is required.Please put "none" if not applicable
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Do you need refills of any of these medications* This field is required.
Yes
No
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Do you need refills on any prescription pet food?* This field is required.
Yes
No
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Patient's Appetite* This field is required.
Normal
Increased
Decreased
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What type/brand of food are you feeding your pet? * This field is required.
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How long have you noticed this change? * This field is required.
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Drinking/Water Intake* This field is required.
Normal
Increased
Decreased
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Is the patient coughing?* This field is required.
Yes
No
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If Yes, patient Coughing* This field is required.
If yes, for how long?
When did you first notice the problem?
Please elaborate
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Is the patient sneezing?* This field is required.
Yes
No
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If Yes, patient sneezing* This field is required.
If yes, for how long?
When did you first notice the problem?
Please elaborate
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Is the patient vomiting?* This field is required.
Yes
No
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If Yes, patient vomiting* This field is required.
If yes, for how long?
When did you first notice the problem?
Please elaborate
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Has the patient had diarrhea?* This field is required.
Yes
No
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If Yes, patient had diarrhea* This field is required.
If yes, for how long?
When did you first notice the problem?
Please elaborate
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Is the patient licking/chewing/itching?* This field is required.
Yes
No
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If Yes, patient licking/chewing/itching* This field is required.
If yes, for how long?
When did you first notice the problem?
Please elaborate
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Do you want us to trim your pet's nails today?* This field is required.
Yes
No
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Any other services you'd like your pet to receive?
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Any other concerns/questions/relevant observations?
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Please upload any relevant photos / videos / records here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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I understand that DVC requires payment at the time services are rendered and does not offer payment plans or deferred billing of any kind. I take full responsibility for the pet(s) I'm presenting to DVC (either in person or virtually via phone/video consult) and agree to be fully financially responsible for paying in full TODAY. I understand and fully acknowledge that if I have a specific budget or any financial concerns or limitations I can ask for a treatment plan which will be provided before any treatments are performed, except for the office visit/exam/consultation, which I agreed to pay in full by coming here (or calling) and presenting my pet(s) or discussing my pet(s) with the veterinarian today. I understand that I can decline some services/goods, (even if against the advice of the veterinarian), if I am unable to pay for everything recommended and I promise to clearly decline items (EXCEPT the office visit/consultation/exam-which cannot be declined) if financially necessary BEFORE they are performed.

If you have budget constraints, kindly let us know before we see your pet.
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Do you need a treatment plan with cost estimate before we treat your pet today?* This field is required.
Yes
No
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Signature* This field is required.
Clear
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Please verify that you are human* This field is required.
Should be Empty: