Medical Concern Appointment Form Owner Name*Phone*Pet's Name*Species Dog Cat Appointment Preference* In-Person CurbsideReason For Visit: (Check all that apply)* Illness Injury Recheck OtherWhat symptoms has your pet been experiencingAre 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 SicknessWhere are the skin masses located?When the the problem(s) start?Have the symptoms changes since you first noticed them? No Change Worsened ImprovedHas your pet experienced this problem in the past?* Yes NoIf yes, please elaborateIs 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 OtherHas your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes NoPlease explain:NameThis field is for validation purposes and should be left unchanged.