Patient History (Pre-Appointment) Form

Please complete this form the day before or morning of your appointment. If you have any contagious illness symptoms, please phone us so that we can make a safe plan for your pet's visit together.

Location

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Your Name*

All questions in this form (including name and contact details) refer to the person accompanying your pet to the appointment.

What is your preferred pronoun?

Your Email Address*

Your Phone Number*

Pet's Name *

When is your appointment? (date & time)*

What is the reason for your visit?*

Please describe your major concerns about your pet. When did they begin? How have they progressed?*

How are your pet's energy levels? Any changes?*

How is your pet's appetite? Any changes?*

What does your pet normally eat each day (brand, flavour, quantity)? Have you changed your pet's diet recently, or have they eaten anything new?*

Please also bring a picture of your pet's food package(s) to your appointment.

Please list any medications or supplements that your pet currently gets.*

Please include the dose you are currently giving them, and how often they get each medication or supplement.

Has your pet had any vomiting or diarrhea?*

If so, please provide details (when it started, frequency, appearance.

Has your pet been coughing or sneezing? Do they have any discharge from their eyes or nose?*

Has your pet been itching/scratching? Do they have any lumps, bumps or lesions?*

How is your pet's mobility? Have you noticed any changes?*

Has there been any change in your pet's urination or drinking?*

How much time does your pet spend outside, if any? Where do they go?*

Do you do any home dental care for your pet? If yes, please describe.*

Has your pet had any other symptoms or changes in behaviour?*

Has your pet previously had any of the symptoms that you described above?

Does your pet have any previous health issues that we may not be aware of? If so, please describe.*

Do you have any specific questions for the veterinarian?

Have we prescribed or suggested your pet take calming medication before their visits with us?*

Yes
No
I'm not sure

If yes, please list the name, strength, and quantity of calming medication you gave/will give to your pet, and the time(s) it was administered/will be given

Does your pet have health insurance?*

Yes
No

If no, would you like a free pet insurance trial?

Pet insurance can help ensure that you can treat your pet if they have an accident or develop a health issue that requires expensive medical care. Most pet insurance companies offer free trials on the same day as a vet exam. If you are interested, please ask us about insurance during your appointment. (Free trial options are available for pets 8 weeks to 14 years old - older pets are still eligible for insurance, but not for free trials).

Yes
No
I’m not sure yet / I have questions about pet insurance

If yes, please provide your insurance company name and policy number (skip if we already submit insurance claims for you)

If you have Trupanion, OVMA or PetSecure insurance, we can submit your claims electronically for you - just ask! For other insurance companies, please ask us about signing a master insurance claim form so that we can help you submit your claims.

Security Question*

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY **