East Lansing Veterinary Clinic Appointment History

CURBSIDE CARE - Pet Health Questionnaire

Thank you for allowing us to care for your pet! Please complete this form prior to your pet's appointment. This helps us move more efficiently through our curbside appointments. Please note that not having this completed prior to your appointment may delay your appointment.
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.
Owner's Name *

First Name Last Name
Have you moved or changed your contact information (cellphone, email etc) at all in the past year?

No Yes
Please type updated information below:
Pet's Name *
Date and Time of Appointment

Month Day Year
Date
Hour Minutes AM/PM Option
Canine or Feline *

Canine Feline Other
Male or Female

Male Female
Is your pet Spayed/Neutered

Yes No
Is your cat:

Indoor Outdoor Indoor/Outdoor
When was your pet's last heat cycle?
Has your pet been exposed to un-neutered males?

Yes No
Your Pet's History

If you mark abnormal on any item, please use the box below the tables to describe what is abnormal. Please include items such as duration of symptoms, change in symptoms or any other pertinent information you can think of. More information is always better!
Is your pet's energy level normal? (Consider what is normal for them when answering) *

Yes No
Please describe symptoms, when they started and how long it has been going on:
Is your pet eating and drinking normally? *

Yes No
Please describe symptoms, when they started and how long it has been going on:
What brand of pet food do you feed, how much and how often: *
Please List All Medications, Preventions, Vitamins and Supplements your pet is currently taking: *
Has your pet had any vomiting/diarrhea/coughing/sneezing? *

No Yes
Please describe symptoms, when they started and how long it has been going on:

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?

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

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 *

Month Day Year
Date
Should be Empty: