Please fill out this form the evening before your dog’s visit. Please bring a fresh fecal sample to your dogs appointment. If there is any diarrhea, vomiting or coughing please keep your dog in the car when you arrive and call 704-487-7595 to let us know you have arrived.

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Name *

First

Last

Cell Number *

Pet's Name *

Name and Cell Number of person bringing pet to appointment *

I understand that I am financially responsible for decisions made by the person that brings my pet to the appointment.

Address *

We want to be sure your address is current on file.

Change in appetite?

• No
• Increase
• Decrease

Vomiting?

• Yes
• No

If vomiting- How much? How often? Appearance(whole food, blood)

Weight gain or weight loss?

• Gain
• Loss
• No change noticed

What do you feed your pet, how much and how often? *

Also include treats and any human food your pet is given.

Excessive scratching or itching?

• Yes
• No

Any scooting, chewing, or licking at bottom?

Lumps or Bumps?

Any dental problems? *

• Yes
• No

Description of dental problems

For example- bad breath, tartar, blood in mouth, chewing different

Decreased energy levels?

• Yes
• No

Any stiffness getting up or down, difficulty jumping? Please describe.

Coughing, sneezing or difficulty breathing?

• Yes
• No

Describe if yes for coughing, sneezing or difficulty breathing?

Any change in bowel movements please describe(consistency or frequency)?

Change in drinking?

• No change
• Increase
• Decrease

Change in urination?

• No change
• Increase
• Decrease

Eye problems?

• None Known
• Vision Changes
• Discharge
• Rubbing eyes

Please mark all that apply

Ear problems?

• None Known
• Head shaking
• Scratching
• Odor
• Discharge

Please mark all that apply

Do you board your pet, take to day care or grooming?

• Yes
• No

Does your DOG travel out of state? *

• Yes
• No

Respond NO if patient is a cat

What monthly preventatives does your pet take for heartworms, fleas, ticks or other deworming? *

Please list the name and frequency of each product.

Please list all other medications and supplements your pet currently receives and their frequency. *

Please note any concerns you have that are not on this list so we can address them as well.

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