Pre-Appointment Form Owner Name*Phone*Pet's Name*Species* Dog Cat Appointment Preference* In-Person CurbsideReason For Visit: (Check all that apply) Wellness Recheck Injury Illness OtherDog Vaccines DHPP (Distemper/Parvo Combo) Lepto Rabies Bordetella Influenza (required by many boarding facilities) Lyme Unsure, would like to discuss recommendations with veterinarianCat Vaccines FVRCP (Distemper Combo) Rabies Feline Leukemia (FeLV) Unsure, would like to discuss with veterinarianOther Procedures Anal Gland Expression Nail Trim Ear CleaningAre there any concerns for the following: (check all that apply) Increase in appetite Decrease in appetite Increase in thirst Decrease in thirst Weight Loss Weight Gain Itching/Scratching Shaking Head Bad Breath Vomiting Diarrhea Constipation Urination Issues Excessive Sleeping Difficulty Rising Scooting Skin Masses Behavioral Problem Car Sickness OtherWhat symptoms has your pet been experiencing?Where are the skin masses located?When did the problem(s) start?Have the symptoms changes since you first noticed them? Worsened Improved No ChangeHas your pet experienced this problem in the past? Yes No UnsurePlease ExplainIs your pet on any medications?* Yes NoIf yes, please specify which medication(s), dosing, and last time of administrationWhat kind of food do you feed your pet?*How much do you feed?* Free Feed (food is always offered/whenever hungry) Measured amount (specify how much and how often below)UntitledDoes your dog come into contact with other dogs? (check all that apply) Boarding Dog Parks Grooming None Training OtherHas your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes NoPlease explain:Do you have insurance for your pet? Yes No Would like to discuss at appointmentIf yes, what insurance?Do you give your pet heartworm or flea/tick preventative? Yes NoWhat brand and when was it last administered?Do you need any refills of medication or prevention? Yes No Unsure, would like to discuss with veterinarianWhich one(s)?About how much time does your pet spend outside a day?Is there anything else you would like to discuss during your visit?Was your pet's last vet visit at Central Veterinary Hospital (any location)? Yes NoWho was your pet's last veterinary clinic and when were they last seen?PhoneThis field is for validation purposes and should be left unchanged.
