Patient Intake & Client Covid19 Screening Form

Client's Information
Please list the name & cell number of the owner that will be in our parking lot for the appointment.
Name*
First Last
Cell Phone
Covid19 - Have you recently travelled outside of Canada?
Covid19 - Are you or anyone in your household currently in self-isolation? If so, please provide details.
Covid19 - Do you have any of the following Coronavirus signs or symptoms? Fever, chills, difficulty breathing, shortness of breath, cough, sore throat, trouble swallowing, runny nose/stuffy nose, nasal congestion, decrease or loss of smell or taste, nausea, vomiting, diarrhea, abdominal pain, not feeling well, extreme tiredness, sore muscles. If so, please provide details.
Pet Information
Pet's Name*
Please list any specific concerns or questions you would like addressed during the appointment.
Does your pet have any allergies?
Has your pet ever reacted to a vaccination?
How is your pet's appetite?
What food are you currently feeding your pet? How often? How much daily?
What treats do you give your pet? How much and how often?
May we give your pet treats during the appointment?
Has there been any change in your pet's water intake? If so, for how long and is it increased or decreased?
How is your pet's energy level? Has there been any change in it?
Has there been any vomiting or diarrhea? If so, please provide details.
Has there been any coughing or sneezing? If so, please provide details.
Does your pet's urination seem normal? Do you have any concerns?
Is your pet currently on any medications or supplements? If so, please provide details.
Has you pet been boarding or travelled recently? If so, please provide details.
Are there any mobility or lameness concerns with your pet?
Are there any skin lesions or lumps/bumps on your pet?

Patient Intake & Client Covid19 Screening Form

Client's Information

Pet Information

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