Appointment Questionnaire | Animal Doctor in Junction City, KS

First name *

Last name *

Preferred contact number. *

Patient name *

NEW PATIENTS ONLY: How long have you had the patient?

NEW PATIENTS ONLY: Where did you get him/her?

NEW PATIENTS ONLY: Is the patient microchipped?

NEW PATIENTS ONLY: Vaccination history (be specific)

NEW PATIENTS ONLY: Does the patient have any underlying conditions?

NEW PATIENTS ONLY: If yes, please explain.

What changes have you noticed? *

How long have you noticed a change? *

Does your pet experience/have (check all that apply): *

How is your pet's appetite? *

What kind of food are you feeding? How much per day? *

How is your pet's thirst and urination? *

Have you tried anything at home? Do you brush or give dental treats? *

Any history of allergies/chewing fur/excessive grooming? *

When was his/ her last dental cleaning? *

Is the patient on any medications? Include dosage and frequency. *

Are you administering heartworm preventative? What type and how often? *

Are you administering flea/ tick preventative? What type and how often? *

Do you have any additional questions or concerns you would like to address with the Doctor today? *

Animal Doctor Westside