Problem visits including lameness, heart problems, diarrhea, vomiting, coughing, urinary problems, injuries, skin, ears, diabetes

Please fill out this form the evening before your pet’s visit.

If there is any diarrhea, vomiting or coughing please keep your pet 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)? Please bring a fecal sample if there is any diarrhea or a change in stool consistency.

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

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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