*** THIS FORM IS FOR EXISTING APPOINTMENTS ONLY *** • • • CLIENT INFORMATION • • • Please fill out this form for existing appointments only. (*required) Your Name* Your Address* Your Phone Number* Your Pet's Name* Required only for curbside (not needed if you are coming inside): Phone number to be used at this appointment: Car make and color: • • • VISIT INFORMATION • • • It is OK to give your pet clinic treats? (Please bring your own for us to use if not.) YesNo What do you feed your pet? "*IMPORTANT* Please be specific about the brand, flavor/protein, amount fed per day. Our doctors need this information to make appropriate diet/weight recommendations for your pet. What medications and supplements do you give your pet? Please include amount given. Is your pet currently receiving parasite prevention? YesNo If yes, please tell us the brand and type of parasite prevention. Would you like preventatives refilled or prescribed today? Please choose: Heartgard Plus, Nexgard, Simparica Trio.We recommend year round (12 months) heartworm prevention with Heartgard or Simparica Trio (also a flea and tick preventative). Nexgard is also available for flea and tick prevention. What is the main reason for your visit today? Wellness/vaccinesMedical concern Do you have any other questions or concerns you would like to discuss at today's visit? ( 860 characters left) Please describe your primary medical concern. When did it start? Are signs improving or worsening? Have you given any treatment for it at home? Please use the prompts below to give us more details about your pet's symptoms: How is your pet’s appetite? —Please choose an option—normalincreaseddiminished Have you noticed any change in water consumption? —Please choose an option—morelessno change Have you noticed any diarrhea or changes in stool? YesNo Please explain: When did the diarrhea start? Has there been recent changes to food or treats, or has your pet gotten into something (garbage, toys, etc.)? What color is your pet's stool? Any blood or mucous? Have you noticed any vomiting? YesNo Please explain: Could your pet have eaten or chewed up something toxic or possibly dangerous (clothing, toys, etc.)? What does the vomit look like? When did the vomiting start? Any recent changes to food or treats? Have you noticed any coughing/sneezing/discharge or other respiratory signs? YesNo Please explain the respiratory signs you have noticed in your pet. For dogs: Any exposure to other dogs (ex: dog parks, day care, groomers, classes or playdates) in the last 2 weeks? For cats: Any exposure to new cats or recent changes in household or routine in the last 2 weeks? Have you noticed any limping/pain/stiffness or other mobility issues? YesNo If yes, please explain the signs of mobility issues you have noticed in your pet. When did it start? Is it better, worse, or staying the same? —Please choose an option—BetterWorseStaying same Is it better after rest? —Please choose an option—YesNoSameDon't know Is it worse after exercise? —Please choose an option—YesNoSameDon't know Which leg is your pet limping on? Does it seem to shift from one leg to another? —Please choose an option—YesNoDon't know Was it preceded by any known injury or trauma? —Please choose an option—YesNoDon't know Have you noticed any skin or ear issues, such as itching, head-shaking, chewing, or scooting? YesNo If yes, please explain the signs of skin/ear issues you have noticed in your pet. Have you noticed any new lumps or changes in existing lumps? YesNo Please explain the character of the change of existing lumps, or when you noticed the new lump. Has the new lump changed since first noticed it? For this appointment, I understand that: Pets must be on leash with secure collar or in a carrier. Signature (Please type your name in lieu of a signature) Δ
