Pet’s Name

Client Name Last, First:

Date

Email Address

Contact Number for Today:

Reason for appointment today, please describe in full what is occurring with your pet:

How long has the reason for todays appointment been going on?

Is your pet on any Current Medications, vitamins, supplements, today or within the last 3 weeks?

What are you feeding your pet (pet brand, food, human food, snacks, treats, chews)?

How is your pet’s appetite, when was the last time your pet ate?

When was the last bowel movement, please describe it?

When was the last urination? Was there any abnormalities or changes to it, increased or decreased?

Have you observed your pet itching, scratching, or chewing at the body? If yes, explain:

Any vomiting observed? If yes what did it look like, how often, and when was the last one?

Any coughing or sneezing? If yes when did it start, please describe it?

Is your pet weak or lethargic, please describe?

Any limping observed? Where at? When did it start?

Has your pet had any weight loss?

Does your pet travel out of state, to the mountain? To the dog park or daycare?

Signature of Client

Please sign in the box below.

Signer Name

Pre-Appointment Form