Client Information Significant Other's Name
Only if applicable
Current Mailing Address * How do you prefer to get your appointment reminders? *
Please select all that apply
Would you like an estimate for your pet's visit? * What places is it ok for us to release your pet's medical records to? *
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Please list anyone else (not listed above) you would like to give permission to bring your pet/s in. Be sure to include anyone who may watch your pet/s while you are away. 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 Patient Information Name * Breed * Age or DOB * Color * Does your pet have a microchip? * Does your pet have health insurance? * Can we take a picture of your pet?
This would be added to their account and potentially used on social media.
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? * What symptoms have any noticed? What symptoms have any noticed? What symptoms have any noticed? What symptoms have you noticed? Please describe what is going on with your pet and the symptoms you are noticing. Do you know how this happened? If yes, please explain. Please describe what you are visually noticing and the location of the injury. Have you changed your pet's diet or exercise? If yes, please explain. When did symptoms start? Have you treated the symptoms at all prior to the appointment? If yes, please explain with what and for how long. Where are the lumps/bumps located? When did you first notice the lumps/bumps? Is your pet actively bleeding? Does your pet have any diarrhea or are they vomiting? Are they painful to touch? Is there a chance that your pet got into something? If yes, please explain. Are symptoms worse at a certain time of day or before/after activity or rest? If yes, please explain Has your pet had a fecal test recently? Do they board or are they around other animals with or without a cough? Did you change your pet's diet prior to symptoms? Has your pet's energy levels changed? If yes, please briefly explain. Are there any other symptoms you would like us to be aware of? Additional Pet Health Questions Is it ok for you pet to have treats and/or peanut butter during the appointment? Would you like your pet to get a nail trim while here? * 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? * 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. *