Pre-Examination Questionnaire Pre-Examination Questionnaire Owner InformationName(Required) First Last Co-Owner Name First Last Phone(Required)Email(Required) Date of Appointment – PLEASE NOTE: Do not request an appointment via this field. This is for appointments already scheduled with our Client Services Team*(Required) MM slash DD slash YYYY Time of Appointment(Required) Hours : Minutes AM PM AM/PM Pet InformationPet Name(Required)Reason for visit(Required)Any recent history of the following? Please check any / all that apply:(Required) Vomiting Diarrhea Coughing Sneezing Drinking excessively Urinating excessively Changes in activity Lameness or mobility problems Appetite abnormalities Itching/scratching None If yes to any of the above, please describe:What do you feed & how much (including treats)?(Required)List all medications, flea/tick and heartworm preventatives, vitamins, and supplements you give, (dose and frequency, if known):Do you need medications refilled?Does your pet travel outside the immediate area? Yes No If yes to the above, where?Cats: Does your cat go outside? Yes No List any other pets in the household:List any past health issues:What is your grooming routine for your pet?How do you like to receive your pet's medications? Clinic Online Is your pet microchipped?(Required) Yes No If no, would you like a microchip? Yes No Other concerns / questions:CAPTCHA Δ
