Stack Vet - Pre-Examination Questionnaire

1

Have you already scheduled your pet's appointment?* This field is required.Please note that all appointment are currently being offered through curbside service.

YESNO

2

Give us a call to schedule an appointment (315) 478-3161

3

Would you like to be present in the hospital for your pet(s) appointment:

YESNO

4

Please be aware, based on time and room constraints we will do our best to accommodate your request, but there may be circumstances where we are unable to bring you into the hospital.

When you arrive at the hospital, please text or call us at (315) 478-3161 to let our team know that you have arrived, and wait in your vehicle for instruction. Once we have a designated room available for you, we will call you to come in and escort you to the room.

You may be asked to provide proof of your vaccination.

5

if Yes, What is the date and time for your appointment?* This field is required.

Date

Hour

Minutes

6

Have you been fully vaccinated?* This field is required.

YESNO

7

We are excited to announce that starting June 1st we will commence welcoming clients to accompany their pet(s) into our hospital. Our new protocol will allow 1-2 FULLY VACCINATED clients to come into the exam room. Clients entering our building will be required to wear a mask.

We will still offer curbside services for those who wish to remain in their vehicles.

At this time, only doctor/patient visits are included in our new protocol.

If your pet is arriving for a technician appointment, or dropping off for grooming, boarding, or surgery; or if you are picking up food/medications, we ask that you remain in your vehicle.

Please be patient with us through this process. We will do our best to make this as stress free as possible for you and your pet.

We will continue to update our clients with any changes we may need to implement with this new protocol. We look forward to seeing you again during your pet's exam!

In an effort to expedite wait times, we ask that you carefully read and fill out the following:

8

Client Name* This field is required.

First Name

Last Name

9

Pet(s) Name* This field is required.

10

Email* This field is required.

example@example.com

11

Phone Number* This field is required.

Area Code

Phone Number

12

What are your concerns today? When did it start?

13

Is your pet taking any daily medications or supplements?

YESNO

14

If yes, which medication, and when was the last dose?

15

Is your pet taking flea/tick and heartworm preventatives?

YESNO

16

If yes, which medication, and when was the last dose?

17

Do you need any refills?

YESNO

18

Amount requested:

19

Have you seen any fleas or ticks on your pet?

YESNO

20

If yes, when?

21

Will your pet need a nail trim or anal glands expressed during today's visit?

Nail Trim

Anal Gland Expression

Both

22

Does your pet have any allergies or reactions to medications?

23

What brand of food(s) are you feeding? How much and how often?

24

Any changes in water intake or appetite?

YESNO

25

If yes, please explain:

26

Any changes in bowel movements or urinary habits?

YESNO

27

If yes, please explain:

28

Any vomiting, diarrhea, coughing, or sneezing?

YESNO

29

If yes, please explain:

30

Any lumps, bumps, scratching or itching?

YESNO

31

If yes, please explain:

32

How are they getting around? Any limping or pain?

YESNO

33

If yes, please explain:

34

Cat owners: Does your cat spend ANY time outdoors? Do they like to hunt?

35

Is anyone in your household allergic to peanut butter?(We will not offer peanut butter as a treat if there is a household allergy)

YESNO

36

We thank you for your continued support, patience and understanding as we implement this new protocol. We look forward to seeing you soon! Please upload any supplemental files or images