New Visit History Form

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New Visit History Form

Thank you for filling out the following form prior to your already scheduled upcoming appointment.

Please note: If you are a new client, this form is NOT a request for an appointment. If you are a new client, or your pet has never been seen at our facility before, you will need to call 614-875-4321 to speak with a staff member to schedule your appointment.

Client Name *

First

Last

Phone

Phone Type

Phone Number *

Pet Name *

First

Last

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? : *

Please let us know what accommodations would could provide for your visit today that would assist you.

Appointment date and time: *

Date

Time

If you would like a curbside visit please list your phone number

Phone Type

Phone Number

Are you (the owner) or anyone living in your home quarantined because of COVID-19 or showing related symptoms? *

Primary Reason for Appointment (please be as detailed as possible) *

Heartworms are spread through mosquito bites and live in a pet's circulatory system. We recommend year round prevention to prevent heartworm disease. What brand of heartworm prevention is your pet receiving?

When was the last dose given to your pet?

Fleas and ticks are external parasites known to spread various diseases. We recommend year round prevention to prevent these the spread of disease. What brand of flea and tick prevention is your pet being given?

When was the last dose given?

Please list all medications and supplements (including over the counter) that your pet is taking:

Do you need any medication refills today? If so, please list the name of the medication and amount needed.

Please select your pet's energy level:

Normal
Increased
Decreased

What brand of food do you feed your pet?

How much food and how often do you feed your pet?

What additional treats, snacks, or human food does your pet receive? Please be specific and indicate frequency.

Patient's appetite

Normal
Increased
Decreased

Water intake/drinking

Normal
Increased
Decreased

Any previous patient history that we should be aware of?

Would you like to ask the veterinarian anything or add any additional information?

What are your pet's favorite treats?

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?

How would you describe your pet's reaction to going to the veterinary hospital?

Eager and Excited
Subdued
Reluctant
Somewhere in between

How and where does your pet travel in the car? (carrier, seatbelt, loose, ect.)

How does your pet behave in the car?

Does your pet show any signs of nausea with car travel, such s drooling or vomiting?

How would you describe your pet around other animals and people?

Does your pet have any sensitive areas that he does not like to have touched or examined by your or others?

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.)

Does your pet like to play with toys? If so what kinds?

Anything else you would like us to know?

Full payment is required at the time services are provided. We accept Visa, Mastercard, Discover card, CareCredit, Scratchpay, and cash payments. Please sign to acknowledge and accept this responsibility. *

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New Visit History Form

New Visit History Form

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