ECV - Preventive Exam Health History

1
Your Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Pet's Name* This field is required.
4
Species* This field is required.
Please Select
Please Select
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Small mammal
Potbellied pig
Other
5
Sex* This field is required.
Please Select
Please Select
Male
Male Neutered
Female
Female Spayed
Unsure
6
Please check the box to acknowledge the following:* This field is required.
In preparation for anesthesia please DO NOT FEED ANY FOOD after midnight unless otherwise instructed by your veterinarian. Your pet can have access to water until their check-in appointment.
7
Please check the box to acknowledge the following:* This field is required.
In preparation for anesthesia your pet should have access to food and water until their check-in appointment. Please bring your pet’s food with you to your anesthesia check-in.
8
Please check the box to acknowledge the following:* This field is required.
In preparation for anesthesia your pet should have access to hay and water until their check-in appointment. Please bring your pet's hay and water bottle or bowl with to your anesthesia check-in.
9
In addition to this history questionnaire, we need you to complete the anesthesia release form. Have you completed the anesthesia release form?* This field is required.
YESNO
10
Please fill out the Anesthesia Release form. When done, click "next".
11
When was {petsName129} last meal/food??* This field is required.
12
Is {petsName129} taking any medications or supplements?* This field is required.
Please Select
Please Select
Yes
No
Unsure
13
What medications, strength and frequency?
14
Is {petsName129} allergic to any medications or supplements?* This field is required.
Please Select
Please Select
Yes
No
Unsure
15
What medication and what occurred?
16
Has {petsName129} had any previous anesthetic complications?* This field is required.
Please Select
Please Select
Yes
No
Unsure
17
What medication and what occurred?
18
Do you give {petsName129} heartworm prevention?* This field is required.
Please Select
Please Select
Yes
No
19
What specific heartworm products do you give?
20
When was the last dose give?
21
Do you administer heartworm prevention year round?* This field is required.
Please Select
Please Select
Yes
No
22
Do you give {petsName129} flea/tick prevention?* This field is required.
Please Select
Please Select
Yes
No
23
What specific flea/tick product do you give?
24
When was the last dose given?
25
If you have other pets, have you seen any fleas or ticks on them? {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
Do Not Have Other Pets
26
What additional concerns or questions do you have?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
What phone number can you be reached at during the procedure?* This field is required.
28
Would you prefer a call or text message after your pet is in recovery?* This field is required.
Please Select
Please Select
Call
Text Message
29
We look forward to seeing {petsName129} soon. In preparation for your upcoming check in time, we ask:

Arrival Time: Please plan to arrive on time for your scheduled Check in Time. This allows us to complete your check-in promptly and ensures a smooth transition for your pet's examination.

Pet Comfort: If your pet feels anxious or prefers to remain in the comfort of your vehicle until we're ready for the examination, please give us a call at the number provided on our sign. If the line is busy, kindly wait a moment and try again.

Check-In Process: Upon arrival, please come inside to check-in for your pet's appointment. Our friendly staff will be ready to assist you and guide you through the process.

Appointment Changes: Should you need to cancel or reschedule your appointment, we kindly ask for at least 48 hours' notice to accommodate other clients.

Leash or Carrier: For the safety of all pets and visitors, please ensure that all dogs are securely leashed and cats are in carriers upon arrival.

Thanks,

East Central Veterinarians Team
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