ECV - Preventive Exam Health History

1
We are looking forward to seeing you soon for your pet’s upcoming appointment. The following health history questions will help us be prepared for your visit.

If you are sick or feel ill please contact the clinic to inform us of the situation. We require the adult pet owner to accompany the pet to the clinic for their appointment, if you are unable to accompany your pet please contact the clinic to discuss options we can provide you.
2
Your Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Your Pet's Name* This field is required.
5
Species* This field is required.
Please Select
Please Select
Dog
Cat
Other
6
Sex
Please Select
Please Select
Male
Male Neutered
Female
Female Spayed
Unsure
7
Have you completed the new patient form?* This field is required.
YESNO
8
Please fill out the New Patient form. When done, click "next".
9
Where did you get {petsName129}?* This field is required.
Please Select
Friend
Pet Shop
Breeder
Shelter
Other
10
How long have you had {petsName129}?* This field is required.
11
Has {petsName129} received any medical treatments (vaccines, deworming, etc.)?* This field is required.
YESNO
12
Please attach a copy of any previous medical records or email them to info@ecv.vet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
What issues/problems is {petsName129} experiencing?
14
When was the issue/problem first noted?
15
Is the problem the same, better, or worse today?* This field is required.
Please Select
Please Select
Same
Better
Worse
16
Has a similar problem happened in the past?* This field is required.
Please Select
Please Select
Yes
No
Unsure
17
What type of food are you feeding your pet?
18
How much do you feed?
19
How often do you feed?* This field is required.
20
Have you seen any ticks on {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
21
Have you seen any fleas on {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
22
If you have other pets, have you seen any fleas on them?* This field is required.
Please Select
Please Select
Yes
No
Unsure
Do Not Have Other Pets
23
What percentage of time does {petsName129} spend outside?* This field is required.
24
Is {petsName129} taking any medications or supplements?* This field is required.
Please Select
Please Select
Yes
No
Unsure
25
What medication is {petsName129} receiving and how often?
26
What additional concerns or questions do you have?* This field is required.
27
We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask:

Please arrive 10 minutes prior to your scheduled time with the doctor to ensure your check-in is complete.

When you arrive, please come inside to check-in for your pet’s appointment.

If you are more than 10 minutes late to your scheduled appointment we will need to reschedule the appointment to ensure other clients are seen in a timely manner.

If you need to cancel or reschedule your appointment, please contact us at least 48 hours before your scheduled appointment.

All pets must be on a secure leash or in a carrier.

Thanks,

East Central Veterinarians Team
Should be Empty:

We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask: