Pre-Checkin Form "*" indicates required fields Before your pet's scheduled appointment with the doctor we ask that you fill out the Pre Check-In Form. This helps you get ready for your appointment with your pet and saves time to help your appointment run smoothly and efficiently.Please be sure to enter all information below and click “Submit” for the form to be emailed to us PRIOR to your appointment. Client Name* Pet's Name* Appointment Date* MM slash DD slash YYYY Appointment Time* Hours : Minutes AM PM AM/PM 1. What brings your pet in today?* Annual Wellness Illness/Injury Recheck Other NotesWhen did the issue start? Is it getting worse or better since you first noticed it?2. Any vomiting or diarrhea?* Yes No When did it start? How often/how many times per day? Any changes to diet, new treats, ingestion of foreign material prior to onset?3. Any coughing or sneezing?* Yes No When did it start? How often/how many times per day? Any nasal discharge and if yes, what color?4. Any changes to urination?* Yes No Increased frequency/going more often? Increased volume? Any blood, accidents, change in odor? Straining/trying to urinate and not a lot comes out?5. How are your pet’s bowel movements?* Normal Diarrhea Trouble defecating Is it watery, soft serve consistency? Any blood? What is the color?Is the stool really firm? How often is the patient defecating?6. Any changes to your pet's drinking?* Yes No Increased or decreased?* Increased Decreased 7. Any changes to your pet's appetite?* Yes No Increased or decreased?* Increased Decreased 8. Any changes to your pet's energy level?* Yes No Increased or decreased?* Increased Decreased 9. Is your pet on any medications or supplements?* Yes No What dose/mg amount? How often? If the pet is feeling sick have you tried any medications or supplements at home for the issue and if yes, what was given?10. Is your pet on any flea/tick/heartworm prevention?* Yes No What is the name of the medication?11. What diet is your pet currently on? What is the name of the food and what is the amount you give and how often do you feed? If you also give treats, what do you give and how often?12. Have you traveled with your pet outside of the Southern California/Los Angeles area?* Yes No Where did you travel and when was the last time?13. Has your pet been to any other veterinary hospital since their last visit here?* Yes No Were any vaccines performed elsewhere? Can we call for records to update our records here?14. Any major medical history the doctor should know about, such as illnesses or surgeries?* Yes No Please explain further15. If you have a cat, what is your cat's lifestyle?* Indoor exclusively Indoor/outdoor Primarily outdoor NA 16. If you have a dog, what is your dog's lifestyle?* Boarding Daycare Grooming Dog parks NA 17. Does your pet have any known allergies, vaccine reactions, or bad reactions to medications?* Yes No Please explain furtherPreferred Email Address* Preferred Phone Number*
