Client Name*
Pet's Name*
Appointment Date*
Appointment Time*
Name of Person Bringing Pet*
Preferred Email Address for Person Present*
Preferred Phone Number for Person Present*
What is your concern that brings you in?*
When did this start? Has it improved, worsened or remained the same?*
What is your pet eating (Brand of food, canned/dry, free fed/amount fed, times fed)?*
Any changes in your pet's diet? Any new treats introduced?*
If yes to either, when?

For the following questions, please characterize the change, when it started.​​​​​​​

Any changes in your pet's eating habits/appetite?*
If yes, please describe.
Any changes in your pet's drinking habits?*
If yes, please describe.
Any changes in your pet's pooping or peeing?*
If yes, please describe.
Any vomiting, coughing or sneezing noted?*
If yes, please describe.
Is your pet itchy? If so, how itchy on a scale of 1-10 (1= not at all, 10= up all night scratching/chewing)?*
If yes, where is your pet scratching/itching?

For each of the following questions, please specify what, how often, when the last dose was, and dose if applicable​​​​​​​

Is your pet on any medication?*
If yes, please describe.
If your pet is on any medications, do you need a refill?*
If yes, please list.
Is your pet on any flea control?*
If yes, please describe.
Is your pet on any heartworm prevention?*
If yes, please describe.
Is your pet current on vaccines?*

Please provide us with a copy of the vaccine history if this is your first visit with us.

Any history of vaccine reactions in the past?*​​​​​​​
If yes, please describe.
Any history of prior medical concerns?*
If yes, please describe.
Is your pet indoor, outdoor, or both?*
Do you have other pets at home?*
If yes, please list.
Any additional comments/concerns?

Please provide us with the name and phone number of the last hospital your pet was seen at if they went somewhere else:

ADDITIONAL QUESTIONS REGARDING COVID-19

Have you or anyone in your household experienced flu-like symptoms recently?*
Have you or anyone in your household tested positive for COVID-19, or been exposed to anyone that has tested positive for COVID19?*
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