APPOINTMENT REQUEST FORM
Please fill this out and Dr. Barrett will contact you to proceed with scheduling.
Date Form Completed
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
To be completed by the animal's owner. Please answer the following questions about your animal:
Animal's Name
*
Species/Breed
*
Age
*
Weight in lbs
*
How is your animal doing? Please list any problems or symptoms you want Dr. Barrett's help with:
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How active is your animal?
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Very Active
Moderately Active
Not Very Active
How would you describe your animal's weight?
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Overweight
Ideal Weight
Underweight
Where does your animal spend most of the time?
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Indoor
Outdoor
Indoor & Outdoor
Do you give any dietary supplements to your animal (for ex. vitamins, fish oil etc)?
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No
Yes
If yes, please list brands and amounts of all (type N/A if none)
*
Current Medications and dosages if possible (type N/A if none)
*
Current Diet (please be as specific as possible)
*
When did your animal last see a vet?
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When did your animal last have bloodwork or other lab work/testing?
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Does your animal have a history of any of the following nutrition responsive disorders? Check if yes, leave this section if no.
Chronic Kidney Disease
Feline lower urinary tract disease
Acute or chronic enteropathy (gastroenteritis or leaky gut)
Diabetes mellitus
Pancreatitis
Dental disease
Food allergies which affect the skin
Obesity
Please summarize any additional medical history:
Submit
Should be Empty: