Consultation Check-In
Please complete the following information to the best of your ability. This is a safe space, so please don't hesitate to be open and honest about your concerns, and we will work through them together. The more details you provide, the more time we can spend discussing and addressing your pet's specific needs.
Client (Pet Owner) Information
Primary Contact Name:
*
First Name
Last Name
Your Pet's Information
Pet Name:
*
Species:
*
Cat
Dog
Sex:
*
Female
Female Spayed
Male
Male Neutered
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Your Pet's General Medical History
How has your pet’s general health been at home?
*
Rows
Normal
Increased
Decreased
Eating / Appetite
Drinking / Water Intake
Urination
Defecation
Have you observed any of these health issues at home?
*
Rows
Yes
No
Coughing
Diarrhea
Itching
Skin Abnormalities
Vomiting
Have you observed any of these potential signs of dental disease at home?
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Rows
Yes
No
Bad Breath
Bleeding Gums
Broken Teeth
Changes in Chewing Behavior
Decreased Activity (i.e., Slowing Down or Acting Old)
Decreased Socialization Behaviors
Discolored Teeth
Drooling
Dropping Food While Eating
Facial Swelling
Nasal Discharge
Non-Healing, Chronic, or Recurrent Facial Wounds
Oral Pain
Poor Grooming or Poor Coat Quality
Resists or Reluctant to Accpet Head Petting
Sneezing
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Your Pet's Medication History
Does your pet have any known allergies to MEDICATIONS?
*
Yes
No
If yes, please list which medications.
Is your pet currently taking any STEROID MEDICATIONS?
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No
Prednisone or Prednisolone
Prednisolone / Trimeprazine (Temaril-P)
Methylprednisolone (Depo-Medrol; Medrol)
Other
Is your pet currently taking any non-steroidal anti-inflammatory drugs (NSAIDs)?
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No
Acetaminophen (Tylenol)
Carprofen (Novox; Rimadyl; Rovera; Vetprofen)
Deracoxib (Deramaxx)
Firocoxib (Previcox)
Ketoprofen (Ketofen; Anafen)
Meloxicam (Metacam; Meloxidyl)
Piroxicam (Feldene)
Robenacoxib (Onsior)
Other
Please list ANY other medications or supplements your pet is currently taking? When were they last administered?
(Please be as specific as possible.)
Please indicate your preferences for oral medications types. We will do our best to consider this when sending medications home in the future.
Rows
Yes
No
Liquid Medications
Pill Medications (Capsules and/or Tablets)
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Your Pet's Dietary History
When did you feed your pet last?
(i.e., last night or this morning.)
Is your pet on a PRESCRIPTION pet food?
*
Yes
No
If yes, what type of prescription pet food is your pet currently on?
Please list the BRAND (e.g., Hill's, Royal Canin, Purina) and formula (for example, i/d or gastrointestinal).
Is your pet on a GRAIN-FREE pet food?
*
Yes
No
Does your pet have any known FOOD allergies?
*
Yes
No
If yes, please list which ingredients.
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Your Pet's Anesthesia History
Please tell us about your pet's pervious ANESTHESIA experiences or about any concerns you may have before moving forward with anesthesia.
*
To support accurate and efficient medical records, we may use audio recording during your pet’s consultation and exam.
*
I have read, understood, and accept what is outlined above.
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