Pre-Appointment Form Owner Name* Phone* Pet's Name* Species* Dog Cat Appointment Preference* In-Person Curbside Reason For Visit: (Check all that apply) Wellness Recheck Injury Illness Other Dog Vaccines DHPP (Distemper/Parvo Combo) Lepto Rabies Bordetella Influenza (required by many boarding facilities) Lyme Unsure, would like to discuss recommendations with veterinarian Cat Vaccines FVRCP (Distemper Combo) Rabies Feline Leukemia (FeLV) Unsure, would like to discuss with veterinarian Other Procedures Anal Gland Expression Nail Trim Ear Cleaning Are 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 Other What 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 Change Has your pet experienced this problem in the past? Yes No Unsure Please Explain Is your pet on any medications?* Yes No If 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) Untitled Does your dog come into contact with other dogs? (check all that apply) Boarding Dog Parks Grooming None Training Other Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes No Please explain: Do you have insurance for your pet? Yes No Would like to discuss at appointment If yes, what insurance? Do you give your pet heartworm or flea/tick preventative? Yes No What brand and when was it last administered? Do you need any refills of medication or prevention? Yes No Unsure, would like to discuss with veterinarian Which 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 No Who was your pet's last veterinary clinic and when were they last seen? EmailThis field is for validation purposes and should be left unchanged.
