Medical Concern Appointment Form Owner Name* Phone* Pet's Name* Species Dog Cat Appointment Preference* In-Person Curbside Reason For Visit: (Check all that apply)* Illness Injury Recheck Other What 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 Sickness Where are the skin masses located? When the the problem(s) start?Have the symptoms changes since you first noticed them? No Change Worsened Improved Has your pet experienced this problem in the past?* Yes No If yes, please elaborateIs 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 Other Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes No Please explain: PhoneThis field is for validation purposes and should be left unchanged.