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We appreciate you taking the time to complete this form prior to your appointment. The completed questionnaire helps us to approach your pets exam in a more planned manor to promote a fear free, low stress experience for your pet while ensuring we answer all of your pet care questions and make a plan for their health care.

On arrival, please remain in your vehicle, and call the office to let the staff know you are here. The medical staff will let you know when they can escort your pet directly to a room. Thank you for helping us try to promote a more quiet, “fear-free” environment for our more shy and anxious patients.

First Name*

Last Name*

Pets Name*

Is your pet a dog or a cat?*

Dog

Cat

Cell Phone Number*

Appointment Date*

MM slash DD slash YYYY

Appointment Time*

Hours

Minutes

AM/PM

Please describe the primary reason(s) for your pets visit today, and any other concerns. Please also include any information that may be helpful in today s appointment.*

How many cats in total are in your household?*

Please list how many litter boxes you have, where they are located, and if they are covered.*

What type of litter do you use?*

Is your cat using their litter box consistently?*

Yes

How often are the litter boxes being scooped?*

What food are you currently feeding your pet (dry/wet) and what brand? Please note number of feedings a day, amount given per feeding and approximately how long this diet has been fed.*

Is your pet on flea/tick preventative?*

Yes

Which flea/tick preventative?

Is your pet on a heartworm preventative?*

Yes

Which heartworm preventative?

Does your pet take any prescription medications?*

Yes

Which Prescription and how often?

Does your pet take any non-prescription pet supplements (i.e. glucosamine, joint care, vitamins)?*

Yes

What non-prescription pet supplements does your pet take?

Does your pet get any "human" medications (i.e. aspirin, tylenol)?*

Yes

Which human medications?

Do you need a refill on any medications today?*

Yes

Which medication and dosage?

Does your dog do any of the following: travel, stay at a boarding facility, see a groomer, go to dog park or other gathering events?*

Yes

Where does your dog go?

Does your cat do any of the following: travel, stay at a boarding facility, see a groomer, or have exposure to cats not in the household?*

Yes

Where does your cat go?

Does your cat go outdoors? This includes walks or time in fenced yard.

Yes

Has your pet been coughing, sneezing, having nasal discharge or do you have any concerns about how they are breathing?*

Yes

Please list breathing concerns.

Has your pet had diarrhea in the last 14 days?*

Yes

How long has the pet had diarrhea and what is the frequency?

Has your pet been vomiting?*

Yes

How often is your pet vomiting, please explain.

Have you noticed any discomfort in chewing, bad breath, or other concerns with your pets mouth?*

Yes

List concerns about you pets mouth.

Do you brush your pets teeth?*

Yes

How often do you brush their teeth?

Are there changes in your pet's drinking and/or urination habits?*

Yes

Please describe your pet's drinking / urination frequency per day.

Has there been a change in your pets appetite?*

Yes

Please list out appetite changes.

Do you have questions or concerns about your pets behavior, attitude, or energy level?*

Yes

Please list out your questions and concerns.

Is your pet showing signs of physical pain, limping, stiffness, or soreness?*

Yes, I would like to discuss this with the vet today

Yes, but this has been addressed previously

Please explain the signs of physical pain, limping, stiffness, or soreness.

Does your pet have problems with one or both of their eyes?*

Yes

What issues does your pet have with their eye(s)?

Does your pet have problems with one or both of its ears?*

Yes

What issue does your pet have with their ear(s)

Would you like your pets nails trimmed while here? *Fee applies*

Yes

Notes for the nail trim?

Is your pet having concerns with anal glands such as scooting or licking?*

Yes

Please explain what anal gland concerns you're experiencing.

Are there any new lumps/bumps or changes in skin?*

Yes

Please explain the lump/bump location, size, and time of finding.

Our clinic recommends annual wellness laboratory testing on all our patients, especially if on long term medications, are you interested in this today?*

Yes

Please list any questions about the annual wellness laboratory testing.

We recommend arriving 10 minutes prior to the appointment. If you are scheduled for a routine, annual exam, we recommend yearly blood work and viral screening, fecals checked twice yearly, and vaccines due updated. We will provide an estimate of what we have in our records that is needed for your pet for you to review when we come to your car.

Please have your pet on a leash or in a carrier.

I authorize care of my pet by the veterinarians and staff of Oakview Veterinary Medical Center as described above and in accordance with their current policies. Changes or additions to this treatment plan will be discussed as needed, either in person or by phone communication, based on the veterinarian’s exam findings and subsequent recommendations. I understand this may involve my pet being accompanied by a staff member during their visit, rather than myself.*

Comments

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Patient Appointment Form