So that our staff may prepare for your arrival, this form must be completed and submitted at least 30 minutes before your scheduled appointment time. Please call us from the parking lot when you arrive, and remain in the parking lot during your appointment (unless other arrangements are made with the doctor).
Your pet's name
Your Full Name
Cell phone number where we can reach you during your appointment
Street Address Line 2
State / Province
Postal / Zip Code
Date of Your Scheduled Appointment
So that we may assess disease risk and customize our health recommendations for your pet, please indicate any of the following that apply
This dog goes/will go to a groomer
This dog goes/will go to dog parks or doggie day care
This dog goes/will go to training classes or dog sporting events
This dog doesn't interact with other dogs outside of my family
This cat is strictly indoors and NEVER slips outside
This cat goes outside on a porch or deck and never touches the grass
This cat is indoor/outdoor (or will be in the future) or escapes to the outdoors
Is your pet currently taking any medication, parasite prevention, supplements, or vitamins?
Please list all medications, parasite preventives, supplements, and vitamins your pet is currently taking.
Does your pet have allergies to any medication, vaccine, or foods?
Please list all of your pet's known allergies
Please list the type, brand, and amount of foods your pet receives. Please include treats.
Does your pet's diet include grain-free or raw foods?
Does your pet need any medication or prescription diet refills today?
Please check all symptoms that your pet is currently experiencing. Explain in the space below.
Lameness or limping
Appetite changes (please describe below)
Increased water drinking
Increase urination amount or frequency
Urinary or stool accidents in the house
Skin and/or ear problems
Behavioral changes (please describe below)
Mouth or tooth problem
Concerns about pet's weight (increase or decrease)
None, my pet seems healthy and I have no concerns
Please provide details about your concerns (duration, frequency, severity, etc.). List any additional information you feel may be helpful to the doctor.
Would you like information about our Wellness Plans for puppies/kittens, adult pets, or senior pets?
My pet is already on a Wellness Plan
Please verify that you are human
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