Pre-Appointment Form Name First Last Pet's Name Please provide your cell phone for easy communication.Are there any other people like a spouse or relative that you would like on your account to authorize medical care? If so, provide their name and phone number.Please provide your address if you have moved and did not tell us your updated address.What is the primary concern for your visit? Annual Exam with Vaccines Medical Concern Surgery Drop Off Sedation Procedure Recheck What are the concerns, if any, that you have for your pet for today's visit? What kind of food does your pet eat? Please provide brand name, diet, wet/dry, quantity fed, and how often.Does your pet take heartworm prevention every month? If so, what brand? Do you need any refills?Does your pet use flea/tick prevention every month? If so, what brand? Do you need any refills?Is your pet having any of these issues? Check all that apply: Not eating or decrease in eating Not drinking or decrease in drinking Increase in eating Increase in drinking Vomiting Diarrhea Not Defecating Not Urinating Urinating too much Going to the bathroom inside the house or out of the litterbox Coughing after playing, drinking, or at night. Sneezing Licking body parts or inanimate objects Itching or Scratching Scooting Aggression Limping or favoring any leg Not wanting to run, jump, or play Other Other Does your pet need any other services that we are unaware of? Nail Trim Anal Gland Expression Weight Check Do you need any medication refills? (Please note that we always advise 2-3 business days for a refill as some medications need to be order.)Do you have any other questions for the Doctor?
