Appointment Check-In Questions – Prairie Animal Hospital

Please complete the following form. A technician will be out as soon as possible to complete the check-in process.

Name *

First

Last

Patient Name *

Email *

Phone Number *

Presenting Concern: (Please include duration of symptoms) *

Is Your Pet Eating and Drinking Normally? Any Changes? *

What is His/Her Current Diet? How Much are they fed daily? *

Has There Been Any Changes to their Urination or Bowel Movements? *

Please Check If Any Of The Following Has Been Observed:

Vomiting
Diarrhea
Coughing
Sneezing

If any of the above symptoms were observed, please describe what it looked/sounded like and it's frequency:

Please list any Medications/Supplements/Flea & Tick Preventatives Your Pet is Currently Taking: (Please include name/dose/frequency if medication was prescribed from a veterinarian other than us): *

When was your pet's last Annual Blood Screening?

Is your pet current on their Rabies vaccination? *

Yes
No
I Don't Know

By submitting this form you are giving consent for the doctor to perform an exam on your pet today *

Yes, I give my consent.

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