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Pre-Appointment Questionnaire
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Pre-Appointment Questionnaire
Pre-Appointment Questionnaire
Client Name
(Required)
First
Last
Patient Name
(Required)
Do you have pet insurance?
(Required)
Yes
No
Who is your Pet Insurance Provider?
Policy #:
Species
(Required)
Dog
Cat
Does your pet board, groom, or spend time at dog parks/doggy daycare with other dogs?
(Required)
None
Grooming
Boarding
Dog Parks/Day Care
Is your cat indoor only, or indoor/outdoor?
(Required)
Indoor Only
Indoor/Outdoor
Outdoor Only
Please list any medications or supplements you give your pet. (Including: heartworm or flea prevention, joint supplements, skin and coat supplements, vitamins, holistic products, etc.)
(Required)
Does your pet need any refills of medications or preventatives today? If so, please list what is needed and quantity. Ex: Simparica Trio qty 6 doses
(Required)
What type (canned or dry) and brand of food does your pet eat?
(Required)
How much and how often do you feed your pet? Ex: 1 cup twice a day
(Required)
What treats does your pet receive, including human foods?
(Required)
What is the reason for your pet’s visit today?
(Required)
Technician only visit (will not be seeing the Veterinarian – if your pet has medical concerns that need to be addressed, please contact our office to reschedule)
Veterinarian visit, wellness, no medical concerns.
Veterinarian visit, wellness and/or medical concerns. (Please see next question to elaborate)
Other:
(Other) Please list reason for pet's visit:
If you have health concerns for your pet, please check all that apply:
Respiratory
Skin
Urinary Issues
Eyes
Ears
Limping/Joint Issues
New or Changing Lump/Bump
Teeth/Mouth (ex: odor, trouble eating, drooling)
Anal Glands (scooting or licking bum)
Diarrhea
Vomiting
Behavioral
Weight Loss or Weight Gain
Other
Please describe your pet’s medical concern in more detail:
