Telemedicine – Behavior Consult – Prairie Animal Hospital

Please fill out this form prior to your scheduled telemedicine appointment.

Please enter Your Name: *

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Last

What is your Pet's Name? *

What is the phone number we have on file? *

What is the email address we have on file? (Note: Email on file must match the email on the PAH app in order to utilize the chat function) *

Please describe the behavior your pet is exhibiting. When and where is it occurring? *

When did this behavior start? *

Has there been any recent changes to your pet’s environment? Please explain (i.e. change in residence, new family members/pets/visitors): *

Does the behavior consistently occur in certain scenarios? Please explain (i.e. at feeding time, during thunderstorms, when a specific individual is present, etc.…): *

Have you reached out to a trainer in regards to this behavior? If so, please name the trainer/organization: *

What steps, if any, have you taken to alter this behavior? *

Is your pet on any medications/supplements? If so, please list them: *

By submitting this form, I give my consent to the staff and doctors at Prairie Animal Hospital to discuss my pet’s medical concerns on the PAH app as a telemedicine appointment. I acknowledge that not all concerns can be addressed using digital resources and I may still have to bring my pet in for an in-person physical exam as may be recommended by the veterinarian during the telemedicine appointment. *

I consent

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