Please have this form completed before coming to the hospital. You can email it back before your appointment or bring it with you. Your pet will be brought into the hospital by a team member, the doctor will do an exam and answer any questions/conversations by phone. Please have your cell phone ready and the number of that phone on this form. Payment services will be curbside as well, and expected after the visit is complete.Client InformationName(Required) First Last Cell Phone Number(Required)Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient InformationPet Name(Required)Date of birth(Required) MM slash DD slash YYYY Species(Required) Dog Cat OtherBreed/Color(Required)Cats(Required)Where does your feline pet reside? Indoor only Outdoor only Indoor/Outdoor OtherSex(Required) Male Female Male/Altered Female/AlteredDate(Required)Please enter todays date MM slash DD slash YYYY Please arrive 10 minutes before your appointment time. You may park in the parking lot on the east side of our hospital. If your pet is scheduled for routine annual exam / vaccinations, we also recommend yearly bloodwork and stool sample checksPlease call our office once you have arrived. 336-275-7266 Please let us know the make, color and model of your car. If you have any respiratory symptoms, fever and/or cough, have traveled recently or are in quarantine/had contact with anyone that may have coronavirus, please be sure to let our staff answering the phone know!Please have your pet on a leash or in a carrier before we come to the car. Please bring a stool sample, so if needed it is available.Medical History QuestionsBriefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.Reason for visit(Required)Coughing(Required)Any coughing? Yes No OtherWhen did it start and how often do they cough?(Required)Sneezing(Required)Any sneezing? Yes No OtherWhen did it start? Is there any nasal discharge? If yes, what color?(Required)Vomiting?(Required)Any vomiting? Yes No OtherWhen did it start and how frequently are they vomiting? Did they get into something?Diarrhea(Required)Any diarrhea? Yes No OtherWhen did it start and how often are they having diarrhea? Did they get into something? Please describe the consistency. Does your pet’s stool look normal in color? If no, is it black or bloody?(Required)Bowel Movement(Required)When was the last time you saw your pet have a bowel movement and what did it look like?Drinking(Required)Any change in how much water your pet is drinking? Yes No OtherAre they drinking more or less water and when did it start?(Required)Urination(Required)Is the patient urinating as he/she normally does? Yes No OtherWhen did it start and is he/she urinating more or less? Have you seen your pet’s urine? If so what was the color and amount?(Required)Appetite(Required)Has your pet’s appetite changed? Increased Normal Decreased OtherPlease describe how? When did they last eat? How long is this been going on?(Required)What does your pet eat?(Required)Brand, name on bag, how much, and and how often.Diet Changes(Required)Any change in diet? Yes No OtherWhen and what did you change? What are you currently feeding your pet? And what amounts and frequency?(Required)Energy(Required)Is your pet lethargic (not active)? Yes No OtherHow long?(Required)Orthopedic(Required)Is your pet here because it is limping? Yes No OtherWhich leg and how long?(Required)Pain(Required)Has your pet cried out? Yes NoWhat was your pet doing when this occurred?(Required)Eyes(Required)Does your pet have a problem with one or both of its eyes? Yes NoWhich eye and describe any drainage or symptoms? How long has this been going on?(Required)Ears(Required)Does your pet have a problem with one or both of its ears? Yes NoWhich ear and describe any discharge or symptoms?(Required)Teeth(Required)Do you have any concerns with your pet’s teeth? Yes NoDescribe concerns.(Required)Skin(Required)Are there any new lumps or bumps you have found? Yes NoWhere are they and how long have they been present? Have they changed in size?(Required)Behavior(Required)Have you seen any behavior changes? Yes No OtherPlease describe the changes.(Required)Please list any treats/supplements/preventative medication your pet is currently taking and when they were last given:Travel history around Alaska or out of state(Required)Other pets in the home?(Required)Is your pet Microchipped?(Required) Yes NoAttach Medical RecordsMax. file size: 128 MB.Δ
