St. Vital - Combined Questionnaire

Pet Appointment Questionnaire

To help us with your pet's upcoming appointment, please take a few moments to complete the following questionnaire.
Pet Name:*

First NameLast Name
Owner Name:*

First NameLast Name
Date and time of appointment:*

Reason for Appointment
What is your primary reason for booking this appointment?*
What health issue needs to be addressed?*
EX: To check a lump, limping, change in behaviour, etc.
What is the frequency of your pet's symptoms?*
Have you given any medications at home? If yes, please provide the name of the medication, dosage, and frequency given.*
If you are unsure of the name, dosage, and frequency of the medication, please send us a picture:

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Has your pet experienced any of the following?*

	Yes	No	If yes, please explain
Weight change
Coughing
Sneezing
Itching
Problems with urination
Vomiting or diarrhea
Decreased or increased appetite
Decreased or increased water consumption
New or growing lumps
Lameness or mobility issues
Other

Diet
Your Pet's Diet

Let us know about your pet's diet so we can assess their dietary needs.
Current Diet Type:*
Current Diet Brand:*
Amount Being Fed:*
Treats/Human Food:*
Which formula/flavor does your pet consume? *
If you are unsure, please upload a photo of the bag/cans of food:

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Eating Habits:*
How is your pet's food measured per meal or are they free fed?*
Activity Level:*

Lifestyle
Lifestyle

Please answer to the best of your ability.
Where does your pet reside?*

IndoorOutdoorBoth
Was your pet on Tick and/or Heartworm preventatives last year?*

Yes, Heartworm preventativeYes, Tick preventativeYes, Combo ProductNo
We've done your homework for you! Due to its excellent safety profile, broad spectrum coverage, palatability and 100% guarantee our team of Veterinarians has made the decision to recommend and prescribe the Nexgard family of products (Nexgard, Nexgard Spectra, and Hartgard) this Tick and Heartworm Season. If your pet was using a different preventative product in previous years our team would be happy to answer any questions you might have at the time of your appointment.
Do you travel with your pet (ie. camping, etc.) or go to dog parks, doggy daycare, or boarding?*

YesNo
Do you brush your pet's teeth or use dental care chews or products?*

YesNo

Is your pet on any long-term medications or supplements?*

	Yes	No	If yes, which medication/supplement?
answer

Additional Comments & Submit
Other problems/comments/concerns (please be as detailed as possible):
Thank you for taking the time to complete this form.
If you have any questions, please give us a call at 204.253.2668.
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Pet Appointment Questionnaire