Guthrie Pet Hospital - Online Appointment Form

Name

First Name Last Name
Email
Cell phone

Area Code Phone Number
Name of pet being examined
Species *

Dog Cat
Date and time of appointment
Pet Information
Please answer the following questions and explain further if you answer yes to any of the questions.
Vomiting

Yes No
Please explain
Weight loss or gain

Yes No
Please explain
Change in Appetite

Yes No
Please explain
Increased Thirst

Yes No
Please explain
Increased Urination

Yes No
Please explain
Coughing

Yes No
Please explain
Sneezing

Yes No
Please explain
Nasal Discharge

Yes No
Please explain
Stiffness/Limping/Lameness

Yes No
Please explain
Behavioral/Attitude Changes

Yes No
Please explain
Soft stools/gas

Yes No
Please explain
Incontinence/Loss of housetraining

Yes No
Please explain
Bad Breath

Yes No
Please explain
Fleas/Ticks

Yes No
Please explain
Itching/Licking/Chewing

Yes No
Please explain
Shaking Head

Yes No
Please explain
Skin/Hair/Coat Changes

Yes No
Please explain
Growths or Lumps (New)

Yes No
Please explain
Eat grass or pet feces

Yes No
Please explain
Diet normally fed
Medications/Supplements regularly given
Questions or concerns
If your appointment is for a DOG, please answer the following questions
Is your dog on heartworm prevention? If so, what is the product name?
Do you travel/hunt/camp with your pet?

Yes No
Does your dog: Board, get groomed, or go to “Dog Parks”,“Doggie Day Care?

Yes No
If your appointment is for a CAT, please answer the following questions
Has your cat been tested for Felv/FIV?

Yes No
Do you travel with your pet?

Yes No
If yes please explain
Is your cat exposed to other cats?

Yes No
If yes please explain
Does your cat go outside?

Yes No
If yes please explain
Does your cat get in cat fights?

Yes No
If yes please explain
Should be Empty:

Pet Information

If your appointment is for a DOG, please answer the following questions

If your appointment is for a CAT, please answer the following questions