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Day-time Admission Questionnaire
Thank you for dropping off your pet with us today. This questionnaire helps to gather health information on your pet. Please be detailed and specific as much as you can.
Today's Date
Date Format: DD slash MM slash YYYY
Name
First
Last
Preferred Phone #
Alternative Phone #
Who do we contact to get permission to make medical or financial decisions?
Pet's Name
Breed
Chip Number
Sex
Colour
Reason for Visit (check all that apply)
Annual Wellness Exam
Six Months Wellness Exam
Vaccinations
Heartworm Screen
Blood Sampling
Faecal Analysis
Tick Fever Screen
Illness
Please specify if you selected 'Illness'
Are there any concerns for: (check all that apply)
Eating
Drinking
Bad Breath
Weight Loss
Itching / Scratching
Difficulty Standing
Scooting
Shaking Head
Lamenen
Vomiting
Diarrhoea
Skin Masses / Lesions
Urination Issues
When did your pet last eat?
Has your pet ever had an adverse reaction to any medications?
Yes
No
If yes, please describe
Has your pet ever had an adverse reaction to any vaccines, sedation, or any procedure?
Yes
No
If yes, please describe
Is your pet taking any medication(s)
Yes
No
If yes, please list medication(s)
Do you need a refill of these medication(s)
Yes
No
If yes, please list medication(s) in need of refill
Please call me if treatment fee will be over:
*if left blank, we will call if the fee is over $100
Additional Services (Please indicate if you would like your pet to receive any of the following services)
Pedicure
Anal Gland Expression
Heartworm Preventative
Microchipping
New Clients
About Us
Our Team
Our Facility
Terms and Conditions
Testimonials
Blog
Services
Medical Services
Dental Care
Dermatology (Skin)
Cardiology
Intestinal Parasite Screening
Wellness Exams
Endocrinology (Hormones)
Surgical Services
Spaying
Neutering
Soft Tissue Surgery
Local Anaesthesia
Patient Monitoring
General Anaesthesia
Preventive Services
Flea Prevention and Control
Heartworm Prevention
Tick Prevention
Vaccinations
Additional Services
Day-time Admission (Drop-off Service)
Pharmacy / Prescription Service
House Calls
Grooming
End-of-Life Care
Microchip Pet Identification
Pet Travel Form
Pet Supplies
Pet Food, Supplements, and Treats
Pet Health
Pet Health Checker
Preventive Health Bundles
Pet Health Library
How-To Videos
News
Pet Portal
Request an Appointment
Request A Refill
Download The App
Apple App Store
Google Play Store
Special Offers
Contact Us
Request An Appointment
Request A Refill
Boarding Request Form
Drop-off Questionnaire