Curbside Exam List
We understand that this new process is still developing and that will mean additional measures from both you and our staff. We are making the best efforts to continue care for your pet during these recent developments. This form is intended to help facilitate the information needed for an exam. Please fill out and submit before your appointment time.
Email address *
Owner's Name (first and last) *
Your cell phone number (xxx-xxx-xxxx)
Pet's Name *
Reason for Visit *
Any Appetite Change?
Clear selection
Brand and Type (wet or dry) of Regular Food
Any Changes in Water Intake?
Clear selection
Has your pet had any of the following symptoms (check all that apply):
Does your dog take flea prevention medicine?
Clear selection
If yes, what brand of flea prevention?
If on flea prevention, date of last dose?
MM
/
DD
/
YYYY
Does your pet take heartworm prevention?
Clear selection
If yes, what brand of heartworm prevention?
If on heartworm prevention, date of last dose?
MM
/
DD
/
YYYY
If labwork is deemed necessary, this is usually in the $335.00 range. An x-ray is $103.65. Do you consent to these tests?
Clear selection
Do you have a financial limit we need to be aware of?
Clear selection
If yes, what amount?
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