Nurse Appointment Medical History Form

Nurse Appointment Medical History Form

404 S. Edgemoor, Bldg 100, Wichita, KS 67218 316-683-4641
Full Name:*
Pet's name:*
E Mail Address:
example@example.com
Phone Number*

Area CodePhone Number
Has your address changed?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the reason for your pet's visit today?*

PedicureExpress Anal GlandsVaccinationsLaser TherapyBandage ChangeProgress Exam after PeriodontalSuture RemovalOther
What food does your pet eat? (brand, how much per day, wet / dry) What treats and table food do you give your pet?
Current medication(s), including preventatives, and/or supplement(s):
Which preventative(s) is your pet on?

Sentinel Spectrum (Heartrowm)Nexgard (Flea/Tick)Revolution (Heartworm/Flea)Seresto CollarNoneOther
When did you give the last dose of preventatives?
Do you need any prescription(s) or preventative(s) refilled at your pet's visit?

NoYes
(If yes, please list which medication(s), strength, and quantity you would like refilled)
Lifestyle of your pet:

Indoor OnlyIndoor-occasional outdoor trips ;)Indoor/OutdoorOutdoor onlyGoes to doggy daycare, boarding, grooming or dog parksOther
Your pet is scheduled for a nurse appointment. If you have any medical concerns, like the ones below, a different appointment will need to be scheduled with a doctor.
- Change in appetite, drinking, urination.
- Vomiting, diarrhea, constipation, other stool abnormalities.
- Coughing, sneezing, nasal discharge, other respiratory signs.
- Mobility concerns: (limping, pain, stiffness)
- Skin or ear concerns: (itching, head shaking, odor, chewing, scooting, new lumps, changes of existing lumps)
I give the doctors and staff at Skaer Veterinary Clinic permission to examine my pet, and I understand that I am responsible for payment of service at the time of my pets dismissal.
Signature:*

Clear
Date:

MonthDayYear
Date
Please submit form within 24 hours of appointment!

A cancellation fee equivalent to the exam fee will be charged for cancellations within 24 hours. Emergency situations are exempt.
Should be Empty: