Exam Intake for Third Pet Examination Intake Form 2.0 For Third Pet This is the form to fill out for your third pet. Only fill this out if you selected that you were bringing in 3 pets in the first form. Thank you.Date of the appointment* MM slash DD slash YYYY Please let us know the date the appointment is booked for, not the date you fill in this form.Primary Owner(s) Name* First Last Email* Third Pet's Name:* Phone (This is the number we will call you):*This is the phone number we will use to call you once the veterinarian has examined your pet so please make sure you have your phone on you and please stay close to the clinic.What is your third pet here for today? (choose the most appropriate option)* Annual Exam/Vaccines or General Health Check First Puppy/Kitten Visit Subsequent Puppy/Kitten Visit Upset Stomach (vomiting and/or diarrhea) Limping/Pain Ear Issues/ Skin Issues (rash, itching, fur-loss) Growths or Lumps on Body Eye Issues Coughing/Sneezing Issues with Urination Follow up exam (monitor issues seen by doctor last 2-4 weeks) Not acting right / other medical visit Annual Exam/Vaccines (or General Health Check). Please Answer All Questions.Any problems/concerns while here? If yes, when did the problem start? Is it better/worse/same?*Living conditions/environment (new pets? indoors only? any other changes at home since last visit? Does he/she go to boarding/grooming/daycare facilities?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*General attitude at home (acting normal?)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any itchy spots where he/she is scratching or chewing at him/herself?*Any vomiting/diarrhea/coughing/sneezing?*Any other information you would like the doctor to know before your pet's exam today?*First Puppy/Kitten VisitWhere did you adopt him/her from? And how long ago? Is this your first time having a puppy/kitten?*Any problems/concerns while here? If yes, when did the problem start? Is it better/worse/same?*Living conditions/environment (How has he/she adjusted to the new home? Will he/she be indoors only or will be going outside? Will he/she be going to boarding/grooming/daycare facilities?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*General attitude at home*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing?*Any itchy spots where he/she is scratching or chewing at him/herself?*Any other information you would like the doctor to know before your pet's exam today?*Subsequent Puppy/Kitten VisitHow are things going since his/her last visit? Any problems/concerns while here? If yes, when did the problem start? Is it better/worse/same?*Diet (Exact brand, amount, frequency). Any treats/people food? Any changes since last visit?*General attitude at home. How is house-training going?*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Itching?*Any other information you would like the doctor to know before your pet's exam today?*Follow up exam (monitor issues seen by doctor last 2-4 weeks)Reason for recheck? Is the problem better/worse/same?*Any changes in living conditions/ environment since the last visit?*Any changes in diet/ treats?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*How did your pet tolerate the medications?*Any new problems/new symptoms since the last visit?*General attitude at home (any behavioural changes?)*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Itching/Licking/Scratching?*Any other information you would like the doctor to know before your pet's exam today?*Coughing/SneezingPlease tell us more about what has been going on. What symptoms are you seeing? When did these start? Are things getting better/worse/staying the same?*If coughing is it wet, dry? Does your pet cough up any fluid? Is it clear/coloured/ mucusy? Worse at certain times of day or during an activity?*If sneezing, is he/she having breathing issues? Any discharge when sneezing and if so is it clear/coloured/mucusy?*Is he/she having any discharge from the eyes?*Do you have any other pets in the household? Are they affected?*Has your pet had recent exposure to pets outside your household (dog parks, boarding, grooming)?* Yes No Unsure Do you know if any other animals your pet was in contact with are also sick?*Living conditions/environment (new pets? indoors only? any other changes?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/ itching/ scratching?*Any other information you would like the doctor to know before your pet's exam today?*Eye IssuesPlease tell us a bit more about what has been going on. When did the current problem begin? Is it better/worse/same? Which eye(s) is/are affected?*Is there any discharge present? Is the discharge watery/coloured/thick?*Does the eye(s) appear to be painful (holding eyes shut/ excessive tears) or itchy (persistent rubbing of the eyes)?*Has your pet’s vision been affected (if yes, was it sudden or over a long period of time?)*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Diet (Exact brand, amount, frequency). Any treats/people food?*General attitude at home (any behavioural changes?)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Itching/Scratching?*Any other information you would like the doctor to know before your pet's exam today?*Upset Stomach (vomiting and/or diarrhea)Please tell us a little bit more about what has been going on. When did the problem start? Is it better/worse/same?*Vomiting? (if yes, then what colour/consistency? Any blood?)*Diarrhea? (if yes, then how many times? is it soft-serve or liquid consistency? What colour? Any blood? Mucus?)*Other GI issues? (Constipation? Straining to poop? Painful/bloated abdomen? Gassy?)*Diet (Exact brand, amount, frequency). Any treats/people food? Any recent changes to the diet (either in flavour or brand)? Is he/she still happy and willing to eat?*Anything he/she could have eaten that he shouldn’t have? (i.e. garbage, people food, found something outside on a walk, human medications etc)*If there are any other pets he/she is exposed to, are they sick as well? (i.e. other pets in the house, other dogs in the dog walking group etc)*General attitude at home (acting normal? lethargic?)*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Is your pet on any external parasite prevention for fleas/ticks/heartworm?*Any changes in drinking/urination (drinking or peeing more often?)*Any coughing/sneezing?*Any other information you would like the doctor to know before your pet's exam today?*Ear Issues/ Skin Issues (rash, itching, fur-loss)Please tell us a little bit more about what has been going on. When did the problem start? Is it better/worse/same? Has he/she had this issue before?*Does he/she have skin/ear issues year round or does it tend to pop up more during certain times of the year?*What signs are you seeing? (licking, chewing, rubbing, scooting rear end)*Are the ears affected? (If yes; shaking his/her ears frequently? any discharge/ odour coming from the ears? hearing issues?)*Do you have other pets? Are they affected? Any humans in the household affected?*Describe your pet’s living condition/ lifestyle (indoors only, any recent changes? Does he/she go to boarding/grooming/ daycare facilities, swimming/ hiking)?*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/discharge from eyes/nose?*Any other information you would like the doctor to know before your pet's exam today?*Limping/PainPlease tell us a little bit more about what has been going on. When did the problem start? Where does he/she seem painful? Is it better/worse/same?*Anything that may have been an underlying cause? (i.e. jumping/falling off furniture, running the park etc)*Has he/she ever had this issue or something similar in the past?*General attitude at home (acting normal? lethargic?)*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Is your pet on any external parasite prevention for fleas/ticks/heartworm?*Any changes in drinking/urination (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing?*Any itchy spots where he/she is scratching or chewing at him/herself?*Any other information you would like the doctor to know before your pet's exam today??*Not acting right / other medical visitPlease tell us more about what has been going on. What symptoms are you seeing? When did these start? Are things getting better/worse/staying the same?*Anything you can think of that may have caused these symptoms?*Living conditions/environment (new pets? indoors only? any other changes at home since last visit? Does he/she go to boarding/grooming/daycare facilities?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*General attitude at home (any behavioural changes?)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Itching/Scratching?*Any other information you would like the doctor to know before your pet's exam today?*Growths or Lumps on BodyPlease tell us a little bit more about what has been going on. When did you notice the lump/growth(s)? Is it better/worse/same? How many lumps have you found and where are they located? Are they painful, bleeding, oozing, smelly?*Living conditions/environment (new pets? indoors only? any other changes at home since last visit? Does he/she go to boarding/grooming/daycare facilities?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*General attitude at home (any behavioural changes?)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking/urinations (drinking or peeing more often?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Itching/Scratching?*Any other information you would like the doctor to know before your pet's exam today?*Issues with UrinationPlease tell us more about what has been going on. What symptoms are you seeing? For example: increased frequency in urination (urinating small amounts of urine frequently), increase/decrease in volume of urine, increased urgency/difficulty urinating (crying/ straining while urinating). Any incontinence (does your pet leak/dribble small amounts of urine)?*When did these symptoms start? Are things getting any better or worse?*Has your pet had accidents in the house (for cats; accidents outside of the litter box?)*Describe your pet’s urine (clear, dark, bloody, discoloured etc), any strong odour to the urine?*Any history of urinary tract infections/urinary blockages/urinary stones?*Living conditions/environment (new pets? indoors only? any other changes at home since last visit? Does he/she go to boarding/grooming/daycare facilities?)*Diet (Exact brand, amount, frequency). Any treats/people food?*Please list any medical issues your pet has had in the past and/or is currently being treated for? Please also include any medications or supplements your pet is taking (name of medication, dosage, frequency etc.)*Is your pet on any external parasite prevention for fleas/ticks/heartworm? Examples include Simparica Trio, Revolution, Bravecto, Advantage Multi etc.*Any changes in appetite or drinking (drinking more?)*Any Vomiting/Diarrhea/Coughing/Sneezing/Licking/Itching/Scratching?*Any other information you would like the doctor to know before your pet's exam today?*Pet Medical QuestionsPlease upload any medical records or documents you were given (optional). Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB, Max. files: 3. acceptable formats: jpg, gif, png, pdf Max 3 files.Please upload pics of the affected areas (optional) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB, Max. files: 3. acceptable formats: jpg, gif, png, pdf Max 3 files.ConsentStool sample: Please acknowledge this reminder to bring in my pet's stool sample.* Yes I am acknowledging the reminder to bring in a stool sample and that lab fees apply. Options will be reviewed with me before any testing is initiated. Do you grant us permission to display images and videos of your pet(s) on our public social media accounts (Facebook, Instagram, Youtube, Twitter, etc)?* Yes No Animal Safety* I am aware that all cats must be transported in an approved carrier and dogs must be brought on leash. We can provide one if forgotten.Signature* Δ
