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Hours & Contact
Monday - Friday: 8:00am - 5:30pm
Saturday: 8:00am - 12:00pm
Sunday: CLOSED
(772) 770-4263
FAX: (772) 778-4571
[email protected]
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Canine Check-In Questionnaire
Owner Name
Your Email Address
How many pets are in the household, and what type?
Are they mostly indoors, outdoors, or both?
Indoors
Outdoors
Both
Are they on any medications (including heartworm prevention)?
Yes
No
Please list all medications and when they were last administered
Have they been boarded recently?
Yes
No
If so, where?
What is your presenting concern? When did you first notice? Has it stayed the same, improved, or worsened?
What is the best phone number to reach you?
Please answer the following questions as completely as possible
Pet Name
What type of food are you feeding?
How much and how often?
Any changes in appetite?
Decrease
Normal
Increase
If yes, how long has change been occurring?
Any change in food or treats? When?
Any change in water intake?
Decrease
Normal
Increase
How long has change been occurring?
Any change in urination?
Decrease
Normal
Increase
How long has change been occurring?
Has there been any urine leakage?
Yes
No
Is your pet aware they are urinating?
Yes
No
When is leakage occurring? Amount?
Any blood in urine? Straining?
Any changes in bowel movements (Consistency, frequency, etc.)?
When did you first notice the changes?
Anything different that your pet could have eaten?
Do they ever get into things they shouldn't?
Has there been any vomiting? If yes, please describe.
How often do they vomit?
How is activity level relative to your pet?
Overactive
Normal
Lethargic
How long have changes been occurring?
Have there been any changes in the household, such as introduction of a new pet, construction, new cleaning supplies, guests, etc.?
Any Coughing, Sneezing, or Eye Discharge?
Yes
No
If yes to any of the above, please describe.
Is there any other information or concerns that you would like addressed?
