We look forward to helping your pet feel better! Please complete the questionnaire below in advance so we can help as soon as possible when you arrive.

• If your pet requires medication in order to stay calm during an appointment, please give at the appropriate time as directed by your veterinarian. If you need a refill or have forgotten to administer your pet’s medication, please call us ASAP at 740-373-9696. Arriving without administering the required medication can result in significant delays.
• Upon arrival please come to the lobby to check in. We know it can be stressful when your pet is ill. If he/she is coughing, vomiting, or not up to date on vaccination, please keep them in your car. We don’t want other pets sick as well. We will give you a buzzer in order to notify you when we can see you.

Illness Pre-Appointment Questionnaire

Name(Required)

First Last

Name of person attending appointment(Required)

First Last

Email(Required)

Pet's Name(Required)

First

Appointment Date(Required)

MM slash DD slash YYYY

Appointment Time(Required)

Hours

:

Minutes

AM PM AM/PM

Do you need an estimate for your appointment today?(Required)

Yes

No

Is your pet up to date on vaccinations?(Required)

Yes

No

Has your pet ever had any kind of a vaccine reaction?(Required)

Yes

No

Is it ok to do blood work if the doctor feels it is necessary?(Required)

Yes

Maybe, depending on what it is.

No

Can we run a test for fecal parasites if the doctor feels it is necessary?(Required)

First Choice

Second Choice

Third Choice

If your pet has lab work, how would you like the results communicated to you?(Required)

Text Message

Email

Phone Call

Environment(Required)

Indoor Only

Indoor and Outdoor

Outdoor

Has there been any recent boarding or contact with other animals?(Required)

Yes

No

If yes, where and when?

Please click any symptoms your pet is experiencing:(Required)

Vomiting

Vomiting with Blood

Diarrhea

Diarrhea with Blood

Constipation

Coughing

Sneezing

Frequent Urination

Not Urinating

Blood in Urine

Itchy Ears

Itchy Skin

Painful

Not Acting Like Themself

Other: Please Explain Below

Please explain in as much detail as possible the symptoms your pet is experiencing. Give the time it started, any causes that you may be aware of, severity, and location. (Example: right side, left side, front left foot).(Required)

Has there been any change in eating habits or what your pet is eating? What does your pet eat on an average day? Please include pet food, treats, dental chews, and any people food or homemade food with the frequency, amount, and brand.(Required)

What medications/supplements is your pet on? Do you need any refills?(Required)

Is your pet on parasite control? What brand and when did you last administer/apply the medication?(Required)

I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of the appointment. The individual bringing my pet to the appointment is authorized to request services and communicate what my pet needs.(Required)