Curbside Check-In

Dear valued clients:

Please take a few moments and complete the below history form prior to your pet’s visit. This information will be sent to our office directly and uploaded to your pet’s medical records. This will help to expedite your curbside check-in process on your arrival to the office. If you are a new client please also fill out our new client form and email this to our office as well.

Your First Name:
Your Last Name:
Email:
Appointment Time:
I will be in this car: (color/model/make):
Best Phone Number for Time of Appointment:
Patient Name:
Breed:
Age:
Sex:
Spayed/Neutered:

Primary reason for appointment (please be as detailed as possible):

Is your pet eating?
Yes, normallyDecreased appetiteIncreased appetiteNo, not at all

Is your pet drinking?
Yes, normallyDecreased drinkingIncreased drinkingNo, not at all

Is your pet urinating?
Yes, normallyDecreased outputIncreased outputNo, not at all

How is your pet defecating?
NormallyDiarrheaHaving trouble defecatingUnable to defecate

Is your pet coughing?
YesNo

Is your pet sneezing?
YesNo

Is your pet vomiting?
YesNoOccasionally

Is your pet having any mobility issues?
NoYes, with front limbsYes, with back limbs

Are there abnormal growths or lumps you would like checked?
YesNoOccasionally

Is your pet indoor only or indoor/outdoor?
IndoorIndoor/Outdoor

Date of onset of symptoms?

What type of food do you feed (brand and type)?

Please list any medications your pet is on:

Do you use flea/tick/heartworm prevention and if so what brands?

Do you need any medication refills?

File Upload (optional)


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