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New Client/Patient Questionnaire

Thank You for reaching out to The Wandering Vet! 

We would love to learn more about your pet to determine if we are a good fit to provide house call care! We are a concierge house call veterinary service, providing care to dogs and cats in the Chicago suburbs and NW Indiana. Please reply to the following questions so we can get to know you and your pet better!

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Your name: *
Address: *
Best phone contact: *
E-mail: *

Contact information for spouse/partner/family who share ownership in your pet's care: 

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Pet's name: 

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Age/DOB of Pet: 

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Gender (spayed/neutered):

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Breed: 

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Color: 

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Approx weight: 

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Please have your vet email “Full Medical Records with Doctor notes” and “Vaccine reminders” to us at contact@thewanderingvet.com.

Medical conditions:

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Current medications/vitamins/supplements (including dose and frequency):

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Current diet (Brand names and flavor/variety are helpful). Kibble/canned/fresh/homecooked/raw? Snacks, treats, people food?:

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Current heartworm/flea-tick prevention (including when last given): 

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Primary concern (sick/wellness/palliative/end-of-life care). Please provide as much detail as you would like so we can understand your concerns and your pet’s needs at this time: 

How did you hear about us? (Anyone we can thank for their referral?):

Current/previous veterinary care provider: 

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Any history of fear, anxiety or aggression (if yes, please explain triggers and remedies):

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Messaging Opt In/Out: 

Do you agree to receive text messages from The Wandering Vet sent from 708-627-3077? 

Message frequency may vary and will include schedule/Confirm Appointments, Provide Customer Support, Update Owner on delivery status of medications. Message and data rates may apply. 

Reply HELP for help. 

Reply STOP or CANCEL to opt-out at any time. For support, contact us at 708-627-3077.

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Required
Privacy Policy & Terms and Conditions. 
Click here to view our Privacy Policy.
Click here to view our Terms and Conditions. 
Opt In/Out Instructions
To Receive Help at any time, text ‘HELP’ to 708-627-3077. 
To Opt Out at any time, text ‘STOP’ to 708-627-3077 to unsubscribe. 

Once we've received your responses and your pet's medical records, we'll reach out to arrange an initial consultation. 

We look forward to learning more about your pet and their needs!

Blessings, 

- Dr. Denise Cudiamat

The Wandering Vet

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