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18
Questions
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1
What is your pet's name and your last name?
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2
What is the name of the person bringing your pet to their appointment?
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3
What is the primary concern(s) you would like us to address at your appointment?
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4
Has your pet recently experienced any of the below symptoms?
Coughing
Sneezing
Regurgitation
Vomiting
Diarrhea
Other
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5
Has your pet had an increase in thirst or urination? Or, is there anything that seems excessive about the volume or frequency? Any urinary accidents?
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6
How is your pet's energy and appetite?
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7
If needed, please detail any unusual symptoms your pet is experiencing, including the frequency and any other relevant details.
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8
Has your pet had any significant behavior changes?
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9
Has your pet traveled outside of Oregon? If so, where (generally speaking)?
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10
Click all that apply to your pet's lifestyle.
Goes outside (for cats)
Interacts with pets outside of your house
Goes to parks, grooming, boarding, or daycare
Exposure to ticks
Hiking/camping/beachgoing
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11
Are there any other pets living with your pet at home? Please specify species.
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12
Does your pet have pet insurance?
YES
NO
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13
Does your pet have a microchip?
YES
NO
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14
What brand and formula of food does your pet eat? What how many cups/cans are you feeding per day?
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15
Is your pet on any medications, supplements, or vitamins?
Please list them using this format - drug name, pill size (mg) or liquid concentration (mg/ml), and frequency given - let us know if you need a refill and we will get it ready Example: Benadryl 25mg capsule: 1 by mouth every 12 hours
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16
Is your pet currently on flea, tick, or heartworm prevention? If so, please list the name of the medication(s) and the last dose given
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17
Are there any other concerns you would like us to discuss at your appointment?
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18
Let us know if we need to acquire records from any other veterinary clinic, specialist, or emergency hospital prior to this appointment.
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19
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