Pre-Visit Questionnaire

Pre-Visit Questionnaire

Hi there! Thank you for choosing us as your pet care provider. Our goal is to make the visit as stress-free as possible for both your pet and yourself. In order to do so, we would like to ask a few questions in addition to making sure you are aware of our Policies and Procedures prior to your appointment. Please complete and submit this information at least 24 hours prior to your scheduled appointment time to help the doctor prepare for your visit.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Which pet(s) will we be seeing during the visit?*
What is the primary reason for the visit?*

Previous Medical History
Has our practice received a copy of your pet(s) past medical records?*

YesNoNot sureNo previous medical history
Do you have a copy of the records available?*

YesNo
Please upload any copies of vaccination records, lab results, doctor notes, or x-ray images below:

Cancelof
Do we have your permission to contact your pet(s) previous veterinary care provider for any medical records?*

YesNo
Practice Name*
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Please enter a valid phone number.
Practice Email
example@example.com

Acknowledgement and Signature

By signing below, you certify that you are at least 18 years of age, are the owner or authorized agent of the pet(s) previously listed, you understand that payment is due at the time services are rendered, and that photos/videos may be taken of your pet(s) for training or marketing purposes.
Please read and check BOTH statements below, then type and sign your name in order to submit your information.
Signature of Owner/Agent*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Current Medical Information