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Curbside History Form
Please have this form completed before coming to the hospital. You can email it back before your appointment or bring it with you. Your pet will be brought into the hospital by a team member, the doctor will do an exam and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment of services will be curbside as well, and expected after the visit is complete.
Curbside appointment:
Please arrive 10mins before your appointment time If your pet is 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.
Park:
Please let us know where you have parked, the make, color and model of your car.
Notifying us of your arrival:
Please call our office once you have arrived
Pet prepared:
Please have your pet on a leash or in a carrier before we come to the car Please bring a fecal and urine sample, so if needed it is available.
Your Name
First
Last
Pet's Name
Phone
Date
Date Format: MM slash DD slash YYYY
Pet Information
Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.
For how long has your pet been experiencing the problem described above?
Has your pet had any coughing?
Yes
No
If yes, please describe the cough.
*
Has your pet had any sneezing?
Yes
No
If yes, is there any other details you can share about the sneezing?
*
Does your pet have any nasal discharge?
Yes
No
If yes, please describe the discharge in detail.
*
Has your pet been vomiting?
Yes
No
If yes, please describe the vomiting episodes.
*
Has your pet had diarrhea?
Yes
No
If yes, please describe her diarrhea.
*
Does your pet’s stool look normal in color?
Yes
No
If no, is it black or bloody?
Yes
No
Has your pet been drinking more?
Yes
No
Has your pet been urinating more?
Yes
No
Have you seen your pet's urine?
Yes
No
If yes, what was the color and amount?
Has your pet's appetite changed?
Yes
No
If yes, describe how?
When was the last time you saw a bowel movement and what did it look like?
What is the name of the food you feed your pet? Is it canned, dry or both? Specifically, what is the volume of food and treats you are feeding per day?
What brand of food do you feed your pet?
How often do you feed your pet?
How much do you feed him or her?
Is your pet lethargic (not active)?
Yes
No
If yes, how long?
Is your pet here because it is limping?
Yes
No
If yes, can you describe what happened or when the lameness started and on which leg?
*
Please list all medications and supplements/vitamins (name, strength, and amount) your pet is on and when they were last given:
Has your pet cried out or acting in pain?
Yes
No
If yes, what was your pet doing when this occurred?
Does your pet have a problem with one or both of its eyes?
Yes
No
If yes, please describe in detail.
Does your pet have a problem with one or both of its ears?
Yes
No
If yes, please describe in detail.
Do you have a concern with your pet’s teeth?
Yes
No
If yes, describe.
Would you like your pet’s nails trimmed while here?
Yes
No
Comment if any concerns with the nails.
Would you like your pet’s anal glands emptied while here?
Yes
No
Comment if any concerns with them. Any scooting or licking?
Are there any new lumps or bumps you have found?
Yes
No
If yes, please describe additional information about the lumps/bumps (location, how long has it been present, etc).
Any additional information that you feel would be helpful in treating your pet. We will do our best to have your pet seen and communicate a plan as quickly as possible
About Us
Services
Boarding
Laser Therapy
Acupuncture Holistic Medicine
Pet Resources
Testimonials
Make An Appointment
Team
Employment Opportunities
New Clients
Links
Online Forms
Take A Tour
Payment Options
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
News
Contact
Pet Portal
Store
Promotions