Intake Form

1
The purpose of this intake form is to:

Find out if Kidney Support Gold is right for your cat

Identify potential medication interactions

Ensure treatment suitability and safety

Get personalized recommendations

Let us help you.

*Anticipate spending around ~2 minutes completing this intake form. An expert will promptly review your case and provide a response as soon as possible within business hours.
2
Has your cat been diagnosed with kidney disease by a veterinarian?* This field is required.
YESNO
3
Has another vet staged the kidney disease? (referring to IRIS staging)* This field is required.
YESNO
4
What stage is your cat's kidney disease?* This field is required.
Stage 1
Stage 2
Stage 3
Stage 4
5
Has a physical exam been done to assess symptoms?* This field is required.
YESNO
6
Is the kidney disease diagnosed as acute or chronic?* This field is required.
Acute
Chronic
7
Are there any acute symptoms, such as sudden changes in appetite, weight loss, or blood in the stool?* This field is required.If you select the option 'Other,' please type any additional symptoms in the provided 'Other' box.
Sudden changes in appetite
Weight loss
Blood in the stool
Other
8
What does your cat currently eat?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Are there any other health issues, such as hyperthyroidism?* This field is required.
Please Select
Please Select
None
Diabetes
Lactating
Sensitive Stomach
Urinary Tract Infection
Hypothyroid
Hyperthyroid
Hyperlipidemia
Arthritis
Bladder/Kidney Stones
Other
Hot Spots
Dental Disease
Liver Disease
Overweight
Heart Disease
Pancreatitis
Cushings/Addisons Disease
Inflammatory Bowel Disease
Seizures/Epilepsy
Other
10
Please specify.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Have you noticed any behavioral changes such as confusion or seizures?
Huge
Large
Normal
Small
Ok
Ok
12
What specific treatment has been recommended or is being followed?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Are there any other medications or supplements being used?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
Are subcutaneous fluids being administered?* This field is required.
YESNO
15
Has any appetite stimulant medication been prescribed?* This field is required.
YESNO
16
Is a kidney-specific diet being followed?* This field is required.
YESNO
17
Please specify.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
Has bloodwork been done?* This field is required.
YESNO
19
Has urine work been done?* This field is required.
YESNO
20
Do you have any specific questions you would like to ask our vet?* This field is required.
YESNO
21
Please type your questions.
Huge
Large
Normal
Small
Ok
Ok
22
What is your cat's breed* This field is required.
Please Select
Please Select
Unknown
Mixed Breed
Abyssinian
American Bobtail
American Curl
American Shorthair
American Wirehair
Balinese
Bengal
Birman
British Shorthair
Burmese
Chartreux
Cornish Rex
Devon Rex
Egyptian Mau
Exotic Shorthair
Maine Coon
Manx
Norwegian Forest Cat
Persian
Ragdoll
Russian Blue
Scottish Fold
Siamese
Siberian
Somali
Sphynx
Tonkinese
Turkish Angora
Turkish Van
23
When is your cat's birthday?* This field is required.
I know his/her birthday
I don't know
24
* This field is required.
Year
Month
Day
25
* This field is required.
Up to two years old
2-6 years old
7-12 years old
13+ years old
26
Please provide your name so our vet can reply via email* This field is required.Usually within 4 hours
First Name
Last Name
27
Please provide your pet's name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Do you have lab results or other documentation you would like to share?Click SUBMIT if you don't
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Max. file size: 10.6MB
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