East Lansing Veterinary Clinic Appointment History

Owner's Name *

First Name Last Name

Pet's Name *

Date and Time of Appointment

Date

Hour Minutes AM/PM Option

Choose One *

Canine Feline

Choose One

Male Female

Is your pet Spayed/Neutered

Yes No

When was your pet's last heat cycle?

Has your pet been exposed to un-neutered males?

Yes No

Is your cat:

Indoor Outdoor Indoor/Outdoor

Does your pet have any behavior concerns we should be aware of? (Fearful, Bite Risk, Dog Aggression, Cat Aggression etc)

Yes No

Please describe behavior:

Reason For Visit:

Choose One

Please tell us about your pet's normal behaviors: *

Normal

Abnormal

Symptom Description

Duration of Symptoms

Energy Level

Appetite

Thirst

Urination

Defecation

Additional Comments:

Has your pet had any of the following: *

No

Yes

When did you first notice symptoms?

How Often is pet having symptoms?

Sneezing?

Coughing?

Vomiting?

Diarrhea?

Itching?

New/Changing Lumps/Bumps?

Did your pet get into anything that could have cause symptoms (new food, new treats, toys, medications/supplements, eating inappropriate things etc)

What brand of pet food do you feed, how much and how often: *

Has your pet had any of the following: *

No

Yes

To what has your pet reacted to?

What were the symptoms?

Any Adverse Vaccine Reaction?

Any Adverse Medication Reaction?

Any Adverse Anesthesia Reaction?

Additional Notes

What Medications/Prevention/Supplements Is Your Pet Taking? (If none, write "none" in first box) *

Are there any other concerns/problems that you would like the doctor to address today? *

While your pet is here with us today, would you like us to perform any additional services? *Additional Fees Apply:

No

Yes

Nail Trim $17

Express Anal Glands $24

Microchip $53

Do you have an additional pet you would like to submit history for?

Yes No

Pet's Name

Choose One

Canine Feline

Choose One

Male Female

Is your pet Spayed/Neutered

Yes No

When was your pet's last heat cycle?

Has your pet been exposed to un-neutered males?

Yes No

Is your cat:

Indoor Outdoor Indoor/Outdoor

Does your pet have any behavior concerns we should be aware of? (Fearful, Bite Risk, Dog Aggression, Cat Aggression etc)

Yes No

Please describe behavior:

Reason For Visit:

Choose One

Please tell us about your pet's normal behaviors: *

Normal

Abnormal

Symptom Description

Duration of Symptoms

Energy Level

Appetite

Thirst

Urination

Defecation

Additional Comments:

As your pet had any of the following: *

No

Yes

When did you first notice symptoms?

How Often is pet having symptoms?

Sneezing?

Coughing?

Vomiting?

Diarrhea?

Itching?

New/Changing Lumps/Bumps?

Did your pet get into anything that could have cause symptoms (new food, new treats, toys, medications/supplements, eating inappropriate things etc)

What brand of pet food do you feed, how much and how often: *

Has your pet had any of the following: *

No

Yes

To what has your pet reacted to?

What were the symptoms?

Any Adverse Vaccine Reaction?

Any Adverse Medication Reaction?

Any Adverse Anesthesia Reaction?

Additional Notes

What Medications/Prevention/Supplements Is Your Pet Taking? (If none, write "none" in first box) *

Are there any other concerns/problems that you would like the doctor to address today? *

While your pet is here with us today, would you like us to update:

No

Yes

Nail Trim

Express Anal Glands

Microchip

Do you have an additional pet you would like to submit history for?

Yes No

WHAT TO EXPECT DURING YOUR CURBSIDE VISIT:

If you've been through this already with us, Welcome Back! You should be a pro now! If this is your first time with us, WELCOME!!

To better serve and prepare you for your visit with us, here are a few items that are important:

1. Arrival - Please arrive on time or 5 minutes early. We are very busy and you being on time helps us keep our full schedule moving as smoothly as we can!

2. Sit! - Please stay in your car! We are still curbisde. This is to keep you and our team safe. There are signs in all the spots with a parking number and a call or text to check in number. No form submitted prior to arrival constitutes checking, so please do so only when you arrive!

3. Phones - Bring a fully charged cell phone to your appointment - We will communicate with you the entire time and a cell phone helps. Please answer the calls too. We have multiple phone lines with different numbers.

4. Stay! - Please do not leave without talking to a team member first! We will work with you to the best of our ability but unknown departures make it harder for us.

5. Estimates - If you are not asked about cost of care prior to, please ALWAYS feel free to ask for a treatment estimate. We don't want any surprises for you. Our team is always willing to discuss this information whenever you need.

6. Duration - Most well pet visits should take about 30 minutes. Sick pet visits may take an hour or more depending on the procedures or diagnostics needed. Urgent care exams will be seen around scheduled appointments and may take 1-2 hours depending on our patient load (this will be explained to you when you schedule this)

7. Payments - we accept all forms of payment. You can pay over the phone or hand your card, cash or check to a team member. We do have PCI compliant storage for credit cards. If you would like to store your card for future use with us, let a team member know and we can save it.

8. Wi-fi - We do have guest Wifi available for you. Call or text when you arrive for the passwords. Passwords are changed monthly for security purposes.

Financial Responsibility: Our office accepts AMEX, Discover, Google/Apple Pay, Visa, Mastercard and CareCredit, along with cash and checks. Full Payment is due at the time of service. Clients with payment concerns are asked to speak to a team member before their exam. We are happy to discuss all charges and provide a written estimate for care prior to services. We offer 6 months, deferred interest financing via CareCredit for clients in need of a credit plan. No other payment plans are offered at this time. We are not required to adhere to any estimates given over the phone prior to your appointment. We will honor estimates less than 30 days old and provided in writing from our office. *

I have read and understand the above terms

As a precaution due to risks associated with COVID-19 our practice is currently operating by curbside care only. This means no clients are to enter the building at any point. Please ensure that you have a charged cell-phone for communications with the care team while your pet is in the building. If you do not wish to keep your appointment please call the office ASAP to cancel. We do charge fees for no-show and same day cancellations. *

I have read and understand the above terms.

Typed Name as Signature *

Date *

Date

CURBSIDE CARE - Pet Health Questionnaire

THIS FORM DOES NOT SIGINIFY CHECKING IN FOR YOUR APPOINTMENT. THIS IS A HISTORY FORM ONLY. YOU MUST STILL CALL OR TEXT WHEN YOU ARRIVE FOR YOUR APPOINTMENT THE DAY OF.

Your Pet's History

Additional Pet Medical History:

Your Pet's History