Pre-Visit Patient History Form

Client Name *

First

Last

Species *

Dog Cat Other

Appointment Date & Time *

Vehicle (color/make/model) *

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

Yes No

Which flea/tick medication do you use? *

List all other medications and supplements your pet is currently taking (medication/supplement name, dose frequency): *

Do you need refills of any medications/supplements today? *

Yes No

Last Date Given *

How is your pet's appetite? *

Normal Increased Decreased

Has your pet had any nausea, vomiting or regurgitation? *

Yes No

How are your pet's bowel movements? *

Normal Abnormal Diarrhea

How is your pet's energy/activity level? *

Normal Abnormal

Please check which, if any, your pet has experienced in the past 2 weeks *

Coughing Sneezing None

Has your pet ever had a seizure? *

Yes No

Does your pet have any behavior issues? *

Yes No

Do you provide any home dental care? *

Yes No Would like to discuss

Has your pet been prescribed any anti-anxiety medications to help decrease fear, anxiety, or stress during vet visits? *

Yes No

Is there anything else you would like to discuss during your pet's visit today? *

Yes No

I understand that access to Mountain View Veterinary Hospital building is limited to employees and pet pet patients only at this time due to the COVID-19 pandemic. For everyone's safety, I understand that I must wear a face mask at all times during any indirect interactions with the veterinary team. *

I have read and understand

I understand that payment is due in full at the time of services 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