*** THIS FORM IS FOR EXISTING APPOINTMENTS ONLY ***
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Effective June 1st, 2026, all credit card transactions will incur a 3% processing charge. This surcharge does not apply to debit card, cash, check, or Care Credit transactions.

    • • • CLIENT INFORMATION • • •

    Please fill out this form for existing appointments only. (*required)




    Required only for curbside (not needed if you are coming inside):


    • • • VISIT INFORMATION • • •

    We are a peanut-free zone.
    To ensure everyone's safety, no peanut containing products or treats are allowed in the clinic.


    YesNo


    YesNo


    "*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.



    YesNo

    If yes, please tell us the brand and type of parasite prevention.

    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.


    Wellness/vaccinesMedical concern

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    YesNo


    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?


    YesNo


    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?


    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?


    YesNo


    When did it start?
    Is it better, worse, or staying the same?
    Is it better after rest?
    Is it worse after exercise?
    Which leg is your pet limping on?
    Does it seem to shift from one leg to another?
    Was it preceded by any known injury or trauma?


    YesNo

    If yes, please explain the signs of skin/ear issues you have noticed in your pet.


    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?

    1. Pets must be on leash with secure collar or in a carrier.


    I freely and voluntarily agree to consent to the use and publication of my name, my image as well as my pet(s) name and image by Lake Harriet Veterinary for any and all purposes including but not limited to: educational, promotional, and advertising through any format, including: photograph, digital, or internet at any time from this date forward, or until such time as I revoke this consent in writing. I freely give this authorization without expectation of compensation.

    I agreeI decline