Pet's Name *

First

Last

Species

Your Name *

First

Last

Email *

Phone *

Additional Phone

Who's phone number is the above-listed number?

It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop-off appointment.

Have you, someone in your home, or your pet experienced respiratory symptoms (coughing, sneezing, wheezing, or fever) in the last 14 days? *

Have you or your pet been exposed to anyone diagnosed with COVID, showing signs of COVID, or has a pending COVID test in the last 14 days?

Have you or someone in your home been asked by a healthcare professional and/or the Department of Health/CDC to quarantine in the last 14 days?

What is the main reason for your pet's visit today?

Has your pet had any:

Coughing
Sneezing
Vomiting
Diarrhea

Please tell us more.

Has your pet experienced any change in weight?

Increase
Decrease
No Change

Describe anything you have noticed that may be contributing to the weight change, including changes in diet/exercise.

Does your pet have any:

New lumps or bumps
Behavioral changes
Changes in mobility
Other issue you would like to address today

Please expand on what you indicated above: *

(Location of new lumps/bumps, changes you've noticed at home or any other concerns.)

My pet's appetite is:

When did you notice this?

My pet's thirst level is:

When did you notice this?

My pet's activity level is:

When did you notice this?

My pet's urination is:

When did you notice this?

My pet eats (pick all that apply):

Wet food
Dry food
People food
Raw diet
Home cooked diet
Other

If other, please specify:

Brand of Pet Food

If prescription diet, what formula?

How often is your pet fed?

How much is your pet fed?

In addition to pet food, what treats or other food does your pet receive? Include any human food, veterinary dental products, bones, rawhides, treats, etc).

Has your pet's diet changed in the last 6 months?

Yes
No
Not Sure

Is it possible for your pet to have: *

Eaten trash
Ingested toxins (rat bait, ant bait, medications, other known toxic substances)
Ingested Mushrooms
Ingested Marijuana
Eaten toys (parts of toys missing, chew up, etc)
Eaten grain free diet for any period of time
Ingested human or animal medications not intended for them or at higher doses than
None of the above

Please tell us more:

Please list any medications, supplements, or topical treatments your pet has received in the past month and when they were last given:

When was your pet's last dose of heartworm preventative?

Date Given (Please type N/A if not on a preventative)

What kind of heartworm preventative do you use?

Name of medication - put unknown if not sure

When was your pet's last dose of flea/tick preventative?

Date Given (Please type N/A if not on a preventative)

What kind of flea/tick preventative do you use?

Name of medication - put unknown if not sure

Is your pet:

Indoor only
Mostly indoor but rarely to occasionally spends time outdoors
Indoor/outdoor
Outdoor only
Outdoor during the day/inside at night

Are there other pet's in the home?

Yes
No
Farm Animals

Does your pet:

Visit the dog park
Get groomed regularly
Compete in dog/cat shows
Attend obedience training
Attend agility/dock diving/search and rescue programs, etc
Board
Attend Doggie Daycare
Travel with you (out of state)
None of the above

Is your pet current on vaccinations?

Yes
No
I am not sure

My pet's vaccines were administered last by:

Feeding Hills Veterinary Clinic
I am not sure where
Other

If other, please specify where: *

Does your pet have a microchip?

Yes
No
I am not sure

Has your pet bitten anyone in the last 10 days?

Yes
No
I am not sure

Does your pet have any known health concerns and/or chronic diseases or conditions?

Is there anything else we should know about your pet?

If yes, please tell us more. If no, please note N/A.

Is there anything else you would like to discuss today?

I understand that access to the Longmeadow Veterinary Clinic building is limited to employees only at this time. *

I have read and understand the above statement.

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone. *

I have read and understand the above statement.

By signing below, I confirm that the above information is correct to my knowledge and I have read and understand all policies listed above. *

Clear Signature

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