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Client Form – Medical Appointment

For all patients with medical appointments that will be addressing a particular area of concern.

Client Form – Medical Appointment

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 802-888-7776 for a faster response.

Updates on COVID-19 – Hospital Policies For All Appointments
*This form is required for all appointments with a doctor. Please fill this form out at your earliest convenience and at least 24 hours before your appointment.

Client Information

Name *

First

Last

Has your phone number changed since your last appointment? *

What is your new phone number? Please indicate the type of number that it is (home, cell, work, etc) *

Has your mailing address changed since your last appointment? *

What is your new mailing address?* *

Address Line 1

Address Line 2

City

State

Zip Code

Are you, or anyone that lives with your pet, exhibiting symptoms of COVID-19 (cough, shortness of breath, fever) or has tested positive for COVID-19? *

PLEASE CALL TO RESCHEDULE 802-888-7776

Can we take a picture of your pet/s? *

This would be added to their account and potentially used on social media.

Patient Information

Name *

Patient Medical Background

If your pet is having diarrhea please bring a fresh fecal sample (no older than 24hrs and needs to be refrigerated if you are not coming right in with it).

If your pet is having urine issues please bring a fresh urine sample (no older than 24hrs old and needs to be refrigerated if you are not coming right in with it).

If your pet is has been vomiting please collect a sample of vomitus for review by the doctor.

Have you noticed any of the following? *

Coughing / Sneezing / Nasal Discharge
Vomiting / Diarrhea
Lameness / Pain / Difficulty standing, playing, and or jumping
Skin / Ear Irritation
Lumps / Bumps
Urine issues
Appetite / Weight Changes
Behavioral Changes (Lethargy / Ataxia)
Trauma / Body injury
Other
None - My Pet is healthy

Additional Pet Health Questions

Is it ok for your pet to have treats and/or peanut butter during the appointment?

Does your pet have any known allergies? If yes, please list them.

Please put NA if the answer is no.

Would you like your pet to have nail trims while here? *

Additional rates may apply

Please list any medications, supplements, or preventatives your pet is currently taking. *

Do you need any medications, supplements, and/or preventatives? *

Is it a challenge to medicate your pet? *

Yes
No
Unsure

What type of food do you currently feed your pet? *

How much do you feed your pet and how often during the day? *

By checking this box you assume full responsibility to pay your bill at time of service. Every attempt has been made to have all charges entered correctly by the end of your visit, but additional charges may occur. Non payment past 30 days may result in service charges and or collections. *

I agree to the above statement.

Ready for a visit?

We proudly serve the pets of Morrisville, Stowe, Waterbury, Jericho, Montpelier, and surrounding areas. We look forward to seeing you and your pet! You may call to book an appointment by clicking the button below.

Book Appointment