Churchville Veterinary Clinic
PRE EXAM QUESTIONNAIRE
Owners Name: *
Pets Name *
Today's Date *
MM
/
DD
/
YYYY
Is any human in your household sick, feverish, or diagnosed with Covid-19 in the past 14 days? *
Primary reason for your pets visit today (If limping, please notate which leg. If a lump or wound has been noticed, please describe the location): *
How long has your pet been experiencing this problem? *
Please describe the symptoms you are noticing: *
Has your pet been eating, drinking, urinating, and having bowel movements normally? If no, please describe. *
Has your pet had any coughing, sneezing, vomiting or diarrhea? If yes, please describe. *
What pet food and what amount are you currently feeding? *
Is your pet on any medications or supplements currently? If yes, please describe. *
Do you need any medication or food refills today? *
Any other information or concerns we should know about today's visit? *
Current Covid-19 Protocol
Thank you for scheduling your pet’s appointment with Churchville Veterinary Clinic. We look
forward to seeing you and your furry family member on your upcoming visit. Due to the Covid-19 outbreak
and restrictions instituted by the state and federal government, we have instituted Curbside services for the
health and safety of you and our team members. Please see the below instructions for what to expect at
your pet’s appointment:


 If anyone has had contact with a person with COVID-19, is under quarantine, or is experiencing flu
like symptoms to please call the office prior to coming in or finding another individual to bring the
patient.
 All visits will be handled curbside. For the safety of you and our staff, only employees will be allowed
to enter the building. Upon arrival, please pull into one of the numbered parking spots outside of
the office.
 Please remain inside your vehicle and TEXT the office at 410.838.0085 to let us know you have arrived
and which numbered parking spot you are in.
 All dogs must be on a leash or inside a carrier (if small). All cats should be secure in a closed carrier.
We do not want to risk any pets getting loose during a transfer to our team member.
 One of our team members will come to get your pet. Team members will not enter your car to
retrieve or return pets! For dogs, please bring them outside the vehicle and allow them out about 6
feet or to the end of the leash. Our team member will put a hospital leash on your pet and remove
your collar and leash to return to you. For pets in carriers, please place the carrier on the sidewalk in
front of your car and step back for the team member to pick it up. Please wear a face mask when
you are in close proximity with one of our team member.
 Your pet will be examined by the doctor in an exam room. Once examined, the doctor will call you
to review the exam findings and discuss any further recommended diagnostics or treatments. When
all agreed upon services are completed, your pet will be returned to your vehicle with any
medications and discharge instructions. If your pet requires a more in-depth workup, we may ask to
keep your pet to complete our evaluation.
 For check out and payment, our Client Service Representative will join the end of the doctor’s call
with you, or call you once medications are together, to collect payment over the phone.
Due to restrictions imposed by the health authorities and state board to preserve supplies and limit contact,
we may not be able to do all of the services that you request. We understand that this may cause some
inconvenience, but we are required to follow the mandates that are in place. It will be at the discretion of
the doctor to determine what may or may not be performed. Once these restrictions are lifted, we will
hopefully be able to get you back to the office soon to perform all other necessary services. We are grateful
that we are able to continue to care for your pet(s) during this difficult time. Please know that we will care
for your pet with the same compassion and gentle care as if you were in the exam room with us! If you
have any concerns or questions about this new process, we are happy to discuss it further to give you peace
of mind! We look forward to seeing you at the office and hope that everyone stays healthy and safe!

Best Regards,
The Doctors & Team Members of Churchville Veterinary Clinic
Please Check the box that you have read and understand our protocol.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy