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Check-In Form
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Owner's Name
*
First
Last
Primary Phone
*
Secondary Phone
Email
*
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Age/Date of Birth
*
Breed
*
Color
*
Previous Veternarian
*
Do you have a confirmed appointment?
*
Yes
No
Appointment Date and Time
*
Date
Time
Reason for visit
*
Is this a recurring problem?
Yes
No
When did the problem first start?
Has it gotten any better or worse in that time?
Better
Worse
Stayed the same
Please describe your pet's diet (brand, quantity fed, number of times fed per day)
*
Do you feed your pet any table scraps or human food?
*
Yes
No
Any change in food or water intake recently?
*
Yes
No
Any changes in urination and defecation?
*
Yes
No
Is your pet currently taking any medication?
*
Yes
No
Please list all medication (name, dosage, and frequency)
*
Is your pet on any heartworm preventatives?
*
Yes
No
What type of heartworm preventatives do you use?
*
Is your pet on any flea/tick preventatives?
*
Yes
No
What type of flea/tick preventatives do you use?
*
Any recent boarding or contact with other dogs?
*
Yes
No
If yes, please explain
*
Is your pet up to date on vaccines?
*
Yes
No
Has your pet had any reactions to any vaccines?
*
Yes
No
If yes, please explain
*
Any other known health issues or medical problems?
Any additional information to give or concerns for the doctor?
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