Client's First Name

Client's Last Name

Patient's Name

What phone number will you be available for the doctor to call during your appointment?

Please review your account information by logging into your pet’s portal. To enter the portal, click the button at the top of this page that says “Patient Portal”. The first time you log in, you will be required to “sign up” for portal access. Make sure to use the same name and email address you use for your account information.

Reason for today’s visit/concerns/questions:

When did you first notice these symptoms?

How often is this happening?

Any coughing, sneezing, vomiting, or diarrhea?

Has your pet ever been treated for these or similar symptoms before?

Have there been any other changes in your pet (appetite, water consumption, stools, urinations, lethargy, etc.)?

Have there been any changes in your pet’s environment recently (family member, move, renovation, using a new cleaner, etc.)?

Is your pet on any medications?

Yes

What brand of food do you feed? How many cups a day?

Does your pet have any anxiety or fear triggers (ex. fireworks, strangers)? *

Yes

Does he/she have any anxiety about coming to the vet?

Yes

How do you feel we could improve their vet visit? Or your visit?

What motivates/excites your pet? Toys? Food?

What flavor treats/foods does he/she like? Cheese? PB? Meat?

Does your pet have any food allergies?

Yes

Do you need any preventatives?

Heartworm Pills

Heartworm Injectable

Flea/Tick pills

How many flea/tick pills do you need?

Do you buy online? -- we can email you a script for our online pharmacy

Yes

Would you like a nail trim today?

Yes

Have you checked out our wellness plans?

Please discuss them further with me

I have reviewed them, Not interested

I have not looked at them

I am already enrolled

Owner's Signature

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Date

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