Pre-Exam QuestionnaireDate Form Completed(Required) MM slash DD slash YYYY Name & Cell phone of person coming to the appointment with pet(Required)What is the reason for your visit today?(Required) Wellness Exam Sick Exam – Please indicate concerns below Recheck Exam – Please indicate progress belowWhat current Heartworm/ Flea/ Tick preventions is your pet taking?(Required) Revolution Plus Heartgard Plus ProHeart Injectable Heartworm Prevention Simparica Trio Interceptor Plus OTC Preventions Trifexis Credelio No Current Preventions Nexguard Plus Bravecto Other / Not ListedCurrent Medications – What medications, supplements, herbal, or OTC treatments is your pet on? Please include dose and frequency (examples, Gabapentin 300mg twice a day; Carprofen 100mg twice daily) Please type "None" if your pet is not taking any medications, supplements, herbal, or OTC treatments(Required)Diet – What brand of food are you currently feeding your pet and how much?(Required)Lifestyle – Does your pet do any of the following?(Required) Goes to daycare/boarding/grooming Goes hiking/to the park Goes outside Travels None of the aboveIs your pet experiencing any of the following (select all that apply)(Required) Vomiting Diarrhea Coughing/Sneezing Lethargy Decreased appetite Increased thirst Abnormal urinating or defecating Behavior changes Weight loss Sores or masses on their skin Scratching/itching/licking of skin Scratching/itching/smell of ears Vision changes Eye irritation/discharge/swelling Teeth – bad breath/tartar/trouble chewing Mobility – Difficult walking/limping/stiffness Other – please indicate below N/A – my pet is not experiencing any issues currently.If Other – please indicate below(Required)Bloodwork is a great diagnostic tool to analyze the patient’s internal health. We typically test a complete blood count, which counts white and red cells and platelets to look for signs of infection, anemia, or basic coagulation issues. A blood chemistry panel assesses internal organ function—liver, kidneys, electrolytes, blood sugar, etc. We also analyze the urine as part of these basic tests. As pets get older, we may also analyze a thyroid value. Our veterinarians recommend annual blood testing of all adult animals, while senior pets should have their blood work checked every 6 months. Bloodwork panels include a urinalysis evaluation for the patient, please bring a fresh urine sample.Please indicate your choice below(Required) Yes! I plan to proceed with bloodwork for my pet. I have additional questions and would like to talk to the veterinarian before blood work is performedFecal exams allow us to test for parasites in our pets. Intestinal parasites are very common and many can be transmissible to humans, so it is important to check your pet's stool at least once a year. Please bring your pet's fresh stool sample with you to your appointment(Required) Yes! I plan to test my pet for parasites during the visit I have additional questions and would like to talk to the veterinarian before a fecal test is performedLearn more about Intestinal Parasite Screening and the importance of Parasite control here.Has your pet ever experienced a vaccine reaction?(Required) Yes NoDo you need anything else while your pet is here today? Additional fees may apply. You may select more than one.(Required) Toe nail trim Anal gland expression Ear cleaning Hygienic trim Medication refill – please indicate below Other – please indicate belowIf Other – please indicate below(Required)Photograph and Video Release: There may be times we would like to share a photo or video of your pet with our social media sites (including but not limited to our website, Facebook, Instagram, etc.) Please indicate your wishes below(Required) I hereby grant permission to use my pet(s) photograph or video on social media, website, promotional materials, etc, without compensation. Materials will become the property of the hospital. I hereby grant permission to use my pet(s) photograph or video on social media, website, promotional materials, etc, without compensation. Materials will become the property of the hospital.Is there anything else you would like us to know about your pet today? Any behavior issues, likes and dislikes, favorite treats, etc?I, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent.I certify that I am 18 years of age or older.I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.I agree to pay for all services rendered and medications, goods, and supplies when purchased.I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.Pet Insurance is encouraged. Visit Pawlicy Advisor for more information.If desired, financing options are available through SunBit, CareCredit and Scratchpay.I understand that a deposit may be required for surgical or medical treatment.Irelease this hospital from any and all liabilities.By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.Owner/Agent Name(Required)Date(Required) MM slash DD slash YYYY Signature(Required)Δ
