Pre-appointment (office call) Form Pre-appointment (office call) Form Pre appointment form (office call) Please have this form completed before coming to the hospital to help the doctor and technician understand your pet's health and address any concerns promptly. You can email it back before your appointment for the doctor to review in advance. Appointment: Please arrive 10 mins before your appointment time unless the pre-appointment form has been completed and emailed to our office. Name * Name First First Last Last Pet's Name * Phone * Email * Briefly describe the reason your pet is here for an exam, such as ear infection, sick, limping or wellness. Please answer all questions below regardless of why your pet is here. * Goals for Today's Visit Has your pet had any coughing? Yes No If yes, please explain how frequent and when it occurs (i.e at night, after playing, unknown, etc). * Has your pet had any sneezing? Yes No If yes, please explain how frequent. * Does your pet have any nasal discharge? Yes No If yes, please explain color, consistency and frequency. * Has your pet been vomiting? Yes No if yes, please explain the frequency this has been happening. Is it right after eating, first this in the AM ect * Has your pet had any vaccine reactions in the past? Yes No If yes, please explain * Bowel Movements Frequency 1X DAILY 2X DAILY MORE THAN 3X DAILY Consistency Normal Loose Hard Any signs of discomfort or straining? Yes No Urination Frequency 3-5X DAILY MORE THAN USUAL Color of urine CLEAR YELLOW DARK Any signs of discomfort or straining? Yes No Any signs of inappropriate urination (e.g., outside the litterbox or in the house? Yes No Drinking Frequency NORMAL INCREASED DECREASED Any changes in thirst Yes No Any signs of excessive drooling or difficulty drinking? Yes No Appetite Increased Decreased Same What is your pet's current diet? (amount and frequency) Medications | Supplements Is your pet on any medication or supplements? * Yes No Medications/Supplements Details Name of Medication or Supplement * Last administered * plus1 Add minus1 Remove Preventatives (click all that apply) Simparica Trio Nexgard Heartgard Frontline Revolution None OtherOther Do you have a concern with your pet's teeth? Yes No If yes, please explain * Are there any new lumps or bumps your have found? Yes No If yes, please explain * Please use this area to write any information that you feel would be helpful in treating your pet today. Signature * signature keyboard Clear Today's Date * Submit If you are human, leave this field blank.
