Behavioral Questionnaire (Add-On Form ONLY. Please send with NP or CP Form)

Veterinary Behavioral Questionnaire

Thank you for considering South Hyland Pet Hospital for your pet's needs. Please complete this form in its entirety so we can provide you and your pet with the best possible care. If you are unsure of an answer or have questions, please contact our team for assistance.
Owner's Name*

First NameLast Name
Preferred Pronouns
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pet's Name
Species

CanineFelineSmall Mammal
Current list of medication(s) and dosages*
What is/are your primary behavioral concern(s)?*
Have you noticed any new/recent changes in your pet's personality?*

YesNo
If you answered "Yes" to the previous question, please elaborate
Have you seen or is your pet experiencing any of the following behaviors?

Jumping, barking, digging or chewingInappropriate urination or defecationExcessive vocalizationReactivity or pulling on leashFear or withdrawal from people or other animalsIntra-household aggressionAggression to people or other animals (lunging, snapping, growling, biting, scratching, grunting)Repetitive behaviors: circling, licking, groomingFear of new things: noises, car rides, objects, situationsDistress when left aloneIncreased reactivity in any situationChanges in activity level: more or lessFear of the veterinary hospitalConcerns with children and pets in the home
Do you consider these behaviors a problem? If so, please elaborate
Are you currently working with a trainer or a behaviorist?*

YesNo
If you answered "Yes" to the previous question, please list which trainer(s) and/or behaviorist(s) you have been working with
Are you currently seeking a consultaion for behavioral medication(s) only? If yes, please elaborate*
Please upload any previous medical records for your pet that our hospital may not have copies of

Cancelof
Is there anything else that you would like us to know about your pet in regards to their behavior?
Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
What to Expect During Your Pet's Appointment

1. When you arrive for your pet’s appointment, please check in from your vehicle via phone call or text message

This is to help us regulate the amount of people and pets in our small lobby. If there is space available or an open exam room, a team member will instruct you to come inside if you choose

*Curbside and Video Chat Appointments will always continue to be available if you wish to remain in your vehicle for your pet’s appointment

**Please be advised that due to limited space, owners may not always be able to accompany their pet during an appointment with a Veterinary Technician (nail trims, blood draws, vaccine boosters, etc.)

2. Face masks are OPTIONAL for all staff and clients while inside the building. If you would prefer our staff wear a mask while working with you or your pet, please let us know.

If you are exhibiting any symptoms of respiratory illness, we ask that you please wear a mask. If you do not have a face mask, staff will provide you with one to wear throughout the remainder of your pet’s appointment.

3. If you are sick and have tested positive for COVID-19, please notify a staff member immediately. We will ask you to wait in your vehicle for the remainder of your pet’s appointment

Thank you for your patience, cooperation and kindness as we work together to provide the best possible care for your pet!
Would you prefer our staff to wear a mask while working with you and/or your pet?*

YesNo Preference
No-Show, Late & Cancellation Policy

Please click on the link below to review South Hyland Pet Hospital's No-Show, Late & Cancellation Policy.

No-Show, Late & Cancellation Policy

Client Rights and Responsibilities

Please click on the link below to review South Hyland Pet Hospital's Client Rights and Responsibilities

Client Rights and Responsibilities
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of South Hyland Pet Hospital to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Veterinary Behavioral Questionnaire

Client Policies and Procedures