Patient Admit Form
With curbside pet drop off and pick up, it will help expedite (pet’s name) appointment if you could fill in the following questions and send it back to the clinic by email before your appointment. Include as many details as you can. Please do not bring the document with you as we are not accepting paper as much as possible. Thank you
Notes prepared by (client name):
Date and time of appointment:
Have you or anyone in your household been diagnosed with COVID-19?
Are you or anyone in your household experiencing symptoms of COVID-19? (cough, shortness of breath, fever) Have you or anyone else in your household been asked to self quarantine or self isolate in the last 2 weeks?
(If you answer yes to any of these questions, we can still see your pet, but we must discuss with you how we can do that safely prior to the appointment)
Reason for appointment.
What are the presenting problems?
When did you first notice these issues?
How has it changed since it started?
Please note the following for us about your pet:
Any vomiting or diarrhea?
Any lameness or stiffness?
Any coughing or sneezing?
Any recent (60 days) travel or boarding?
If you are presenting a cat, does he or she go outdoors?
Current Medications and supplements?
Is your pet up to date on vaccines and flea/tick/heartworm medication?
Current diet including treats:
Are you bringing any samples for your appointment? (eg urine, feces)
What else would you like us to know today?
What is your contact number during the appointment (cell phone in car)
After you have filled out the form, you can copy and paste and send to: firstname.lastname@example.org or print out and bring with you at you appointment time.
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