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Can we provide any accommodations for today's visit such as assistance getting your pet into or out of the building or car, language translation, or something else that we may be able to provide to make your visit more accessible? :
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Please let us know what accommodations would could provide for your visit today that would assist you.
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Appointment date and time: (required)
:
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Are you (the owner) or anyone living in your home quarantined because of COVID-19 or showing related symptoms? (required)
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Primary Reason for Appointment (please be as detailed as possible) (required)
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What brand of Heartworm Prevention is your pet on?
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When was the last dose of Heartworm and Flea/Tick prevention given?
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Please list all medications and supplements (including over the counter) that your pet is taking:
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Do you need any medication refills today? If so, please list the name of the medication and amount needed.
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Is your pet experiencing any of the following (check as many as apply):
Weight loss or Trouble Eating
Vomiting
Diarrhea
Coughing
Sneezing
Limping
Trouble moving around
Behavior concerns
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Please select your pet's energy level:
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What brand of food do you feed your pet?
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How much food and how often do you feed your pet?
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What additional treats, snacks, or human food does your pet receive? Please be specific and indicate frequency.
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Patient's appetite
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Water intake/drinking
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Patient's urination habits
Normal
Straining
Decreased
Blood present
Increased
Dark
Cloudy
Strong/Foul odor
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Please list all of the places where your pet goes:
Fenced in yard
Yard that isn't fenced
Farm
Hiking, Camping or Swimming
Boarding
Grooming
Doggy DayCare
Indoor cat
Outdoor cat
Indoor/outdoor cat
Hunting
Leash walks
Visit friends and family
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Any previous patient history that we should be aware of?
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Would you like to ask the veterinarian anything or add any additional information?
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What are your pet's favorite treats?
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Has your pet ever been prescribed medications to help with a veterinary visit in the past? If so, what medications were they and what kind of result did you experience?
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How would you describe your pet's reaction to going to the veterinary hospital?
Eager and Excited
Subdued
Reluctant
Somewhere in between
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Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end of this form.
Getting in their carrier or the car
Entering the Veterinary Hospital
Other pets and/or people passing by while in the reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look into the ears)
Being taken out of the exam room for procedures
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How and where does your pet travel in the car? (carrier, seatbelt, loose, ect.)
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How does your pet behave in the car?
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Does your pet show any signs of nausea with car travel, such s drooling or vomiting?
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How would you describe your pet around other animals and people?
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Does your pet have any sensitive areas that he does not like to have touched or examined by your or others?
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Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (Nail trims, temperature, ear exam, blood draw, ect.)
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Does your pet like to play with toys? If so what kinds?
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Anything else you would like us to know?
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Would you like to receive text messages from GCVH. We may use this to confirm your pet's appointment, or give you updates about your pet if they are here for a surgical procedure. :
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Full payment is required at the time services are provided. We accept Visa, MasterCard, Discover Card, Care Credit, ScratchPay, and Cash payments. Please type your name to acknowledge and accept this responsibility. (required)
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