You can always press Enter⏎ to continue
BASIC CLIENT AND DOG INFORMATION
These are the questions our technicians and doctors would normally ask in the exam room. You can help us improve our understanding with the process by completing this form online!
9
Questions
START
1
Your Name?
*
This field is required.
Previous
Next
Submit
Press
Enter
2
Primary Phone Number?
*
This field is required.
Previous
Next
Submit
Press
Enter
3
Email?
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
4
Your Pet's Name?
*
This field is required.
Previous
Next
Submit
Press
Enter
5
Approximate Age?
Under 1 year
1 to 5 years
6 to 10 years
Over 10 years
Under 1 year
1 to 5 years
6 to 10 years
Over 10 years
Previous
Next
Submit
Press
Enter
6
Spayed or Neutered?
Female Intact
Female Spayed
Female Unsure
Male Intact
Male Neutered
Male Unsure
Female Intact
Female Spayed
Female Unsure
Male Intact
Male Neutered
Male Unsure
Previous
Next
Submit
Press
Enter
7
Species?
Canine
Feline
Other
Canine
Canine
Feline
Other
Previous
Next
Submit
Press
Enter
8
Dog Breed?
Unknown
Mixed
Affenpinscher
Afghan Hound
Airedale Terrier
Akita
Alaskan Malamute
American Cocker Spaniel
American Eskimo Dog (Miniature)
American Eskimo Dog (Standard)
American Eskimo Dog (Toy)
American Foxhound
American Staffordshire Terrier
American Water Spaniel
Anatolian Shepherd
Australian Cattle Dog
Australian Shepherd
Australian Terrier
Basenji
Basset Hound
Beagle
Bearded Collie
Beauceron
Bedlington Terrier
Belgian Malinois
Belgian Sheepdog
Belgian Tervuren
Bernese Mountain Dog
Bichon Frise
Black and Tan Coonhound
Black Russian Terrier
Bloodhound
Border Collie
Border Terrier
Borzoi
Boston Terrier
Bouvier des Flandres
Boxer
Briard
Brittany
Brussels Griffon
Bull Terrier
Bulldog
Bullmastiff
Cairn Terrier
Canaan Dog
Cardigan Welsh Corgi
Cavalier King Charles Spaniel
Chesapeake Bay Retriever
Chihuahua
Chinese Crested Dog
Chinese Shar-Pei
Chow Chow
Clumber Spaniel
Collie
Curly-Coated Retriever
Dachshund (Miniature)
Dachshund (Standard)
Dalmatian
Dandie Dinmont Terrier
Doberman Pinscher
English Cocker Spaniel
English Foxhound
English Setter
English Springer Spaniel
English Toy Spaniel
Field Spaniel
Finnish Spitz
Flat-Coated Retriever
French Bulldog
German Pinscher
German Shepherd Dog
German Shorthaired Pointer
German Wirehaired Pointer
Giant Schnauzer
Glen of Imaal Terrier
Golden Retriever
Gordon Setter
Great Dane
Great Pyrenees
Greater Swiss Mountain Dog
Greyhound
Harrier
Havanese
Ibizan Hound
Irish Setter
Irish Terrier
Irish Water Spaniel
Irish Wolfhound
Italian Greyhound
Japanese Chin
Keeshond
Kerry Blue Terrier
Komondor
Kuvasz
Labrador Retriever
Lakeland Terrier
Lhasa Apso
Lowchen
Maltese
Manchester Terrier (Standard)
Manchester Terrier (Toy)
Mastiff
Miniature Bull Terrier
Miniature Pinscher
Miniature Schnauzer
Neapolitan Mastiff
Newfoundland
Norfolk Terrier
Norwegian Elkhound
Norwich Terrier
Nova Scotia Duck Tolling Retriever
Old English Sheepdog
Otterhound
Papillon
Parson Russell Terrier
Pekingese
Pembroke Welsh Corgi
Petit Basset Griffon Vendeen
Pharaoh Hound
Plott
Pointer
Polish Lowland Sheepdog
Pomeranian
Poodle (Miniature)
Poodle (Standard)
Poodle (Toy)
Portuguese Water Dog
Pug
Puli
Redbone Coonhound
Rhodesian Ridgeback
Rottweiler
Saint Bernard
Saluki (or Gazelle Hound)
Samoyed
Schipperke
Scottish Deerhound
Scottish Terrier
Sealyham Terrier
Shetland Sheepdog
Shiba Inu
Shih Tzu
Siberian Husky
Silky Terrier
Skye Terrier
Smooth Fox Terrier
Soft Coated Wheaten Terrier
Spinone Italiano
Staffordshire Bull Terrier
Standard Schnauzer
Sussex Spaniel
Tibetan Mastiff
Tibetan Spaniel
Tibetan Terrier
Toy Fox Terrier
Vizsla
Weimaraner
Welsh Springer Spaniel
Welsh Terrier
West Highland White Terrier
Whippet
Wire Fox Terrier
Wirehaired Pointing Griffon
Yorkshire Terrier
Unknown
Mixed
Unknown
Mixed
Affenpinscher
Afghan Hound
Airedale Terrier
Akita
Alaskan Malamute
American Cocker Spaniel
American Eskimo Dog (Miniature)
American Eskimo Dog (Standard)
American Eskimo Dog (Toy)
American Foxhound
American Staffordshire Terrier
American Water Spaniel
Anatolian Shepherd
Australian Cattle Dog
Australian Shepherd
Australian Terrier
Basenji
Basset Hound
Beagle
Bearded Collie
Beauceron
Bedlington Terrier
Belgian Malinois
Belgian Sheepdog
Belgian Tervuren
Bernese Mountain Dog
Bichon Frise
Black and Tan Coonhound
Black Russian Terrier
Bloodhound
Border Collie
Border Terrier
Borzoi
Boston Terrier
Bouvier des Flandres
Boxer
Briard
Brittany
Brussels Griffon
Bull Terrier
Bulldog
Bullmastiff
Cairn Terrier
Canaan Dog
Cardigan Welsh Corgi
Cavalier King Charles Spaniel
Chesapeake Bay Retriever
Chihuahua
Chinese Crested Dog
Chinese Shar-Pei
Chow Chow
Clumber Spaniel
Collie
Curly-Coated Retriever
Dachshund (Miniature)
Dachshund (Standard)
Dalmatian
Dandie Dinmont Terrier
Doberman Pinscher
English Cocker Spaniel
English Foxhound
English Setter
English Springer Spaniel
English Toy Spaniel
Field Spaniel
Finnish Spitz
Flat-Coated Retriever
French Bulldog
German Pinscher
German Shepherd Dog
German Shorthaired Pointer
German Wirehaired Pointer
Giant Schnauzer
Glen of Imaal Terrier
Golden Retriever
Gordon Setter
Great Dane
Great Pyrenees
Greater Swiss Mountain Dog
Greyhound
Harrier
Havanese
Ibizan Hound
Irish Setter
Irish Terrier
Irish Water Spaniel
Irish Wolfhound
Italian Greyhound
Japanese Chin
Keeshond
Kerry Blue Terrier
Komondor
Kuvasz
Labrador Retriever
Lakeland Terrier
Lhasa Apso
Lowchen
Maltese
Manchester Terrier (Standard)
Manchester Terrier (Toy)
Mastiff
Miniature Bull Terrier
Miniature Pinscher
Miniature Schnauzer
Neapolitan Mastiff
Newfoundland
Norfolk Terrier
Norwegian Elkhound
Norwich Terrier
Nova Scotia Duck Tolling Retriever
Old English Sheepdog
Otterhound
Papillon
Parson Russell Terrier
Pekingese
Pembroke Welsh Corgi
Petit Basset Griffon Vendeen
Pharaoh Hound
Plott
Pointer
Polish Lowland Sheepdog
Pomeranian
Poodle (Miniature)
Poodle (Standard)
Poodle (Toy)
Portuguese Water Dog
Pug
Puli
Redbone Coonhound
Rhodesian Ridgeback
Rottweiler
Saint Bernard
Saluki (or Gazelle Hound)
Samoyed
Schipperke
Scottish Deerhound
Scottish Terrier
Sealyham Terrier
Shetland Sheepdog
Shiba Inu
Shih Tzu
Siberian Husky
Silky Terrier
Skye Terrier
Smooth Fox Terrier
Soft Coated Wheaten Terrier
Spinone Italiano
Staffordshire Bull Terrier
Standard Schnauzer
Sussex Spaniel
Tibetan Mastiff
Tibetan Spaniel
Tibetan Terrier
Toy Fox Terrier
Vizsla
Weimaraner
Welsh Springer Spaniel
Welsh Terrier
West Highland White Terrier
Whippet
Wire Fox Terrier
Wirehaired Pointing Griffon
Yorkshire Terrier
Unknown
Mixed
Previous
Next
Submit
Press
Enter
9
What type of Exam do you need today?
Wellness or Annual Exam
Sick Dog
Puppy Exam Series & Education
Surgery or Dental
Tech Visit (Nails, anals, etc)
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Submit