Curbside Check-In FormCurbside Check-In FormMedical History/Risk AssessmentPet's NameOwner's Name First Last Date MM slash DD slash YYYY Reason for visitCurrent medications/supplementsDo you ever give your pet over-the-counter medications (i.e. Aspirin, Tylenol, Advil, etc.)? Yes NoHas your pet been diagnosed with a heart condition or have a history of seizures? Yes NoPlease list any other pet(s) in your household:Dog – Name(s)Breed(s)Cats – Name(s)OtherMouth No Problems Bad Breath Difficulty Eating OtherOtherEyes No Problems Vision Loss Drainage OtherOtherEars No Problems Scratching Odor OtherOtherSkin No Problems Scratching Hairloss OtherOtherAppetite Normal Decreased IncreasedWater intake Normal Decreased IncreasedUrination Normal Decreased IncreasedActivity Normal Decreased IncreasedMobility Normal DecreasedInability to Stand Jump Up RunCoughing No Yes(If Yes) FrequencySneezing No Yes(If Yes) FrequencyVomiting No Yes(If Yes) FrequencyDiarrhea No Yes(If Yes) FrequencyBehavior No Yes(If Yes) FrequencyVaccination status Current NeededNeededWhat do you feed your pet?How often? Once Twice OtherDoes your pet stay Inside Outside BothDoes your pet Got to Park/Trail Travel with you out of the area Board/Get groomedWhat parasite control do you use?CAPTCHAΔ
