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PRE-VISIT QUESTIONNAIRE
MEDICAL CONSULT
First & Last Name
Address
Name of pet we will be seeing?
Who will be bringing your pet in for its appointment?
What is the best phone Number to reach you at the time of your pet's appointment to discuss the concerns you have regarding your pet?
Can you receive a text message at this number?
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Reason for Visit? What issue or concerns do you have in regard to your pet? (Please be specific. When was this first noticed? Has it worsened? Are there any other pets exhibiting the same symptoms?)
Is your pet showing any of the following symptoms?
Coughing
Sneezing
Vomiting
Diarrhea
Seizures
If you checked any of the symptoms above please explain and list duration.
Are there any changes in your pet's eating or drinking habits? (ie. more thirsty, less appetite)
What is the name of the diet you feed? (Wet and or Dry)
How much do you feed your pet a day?
How often do you feed your pet per day?
Has there been any changes to your pet's urinary habbits? If yes, please explain.
Has there been any changes in your pet's behavior? If yes, please explain.
Has there been any changes in your pet's activity level? If yes, please explain. (ie. Less energetic, sleeping more frequently)
Please list your pet's medications and or supplements including heartworm prevention
Is anyone in your household experiencing any symptoms of COVID19 or tested positive for COVID19 that you are aware of within the past 14 days? (fever, cough, shortness of breath, or body aches/chills?) Have any of the individual(s) bringing your pet to the hospital for the appointment been exposed to COVID19 or showing any symptoms of COVID19 in the past 14 days?
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Are you familiar with our COVID Protocol for appointments?
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Would you like us to call you to discuss our COVID protocol before you arrive?
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Do you have any additional information or concerns?
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