Pre-Appointment Questionnaire Pre-Appointment Questionnaire Name* First Last Email* Phone*Pet's Name* What problem has your pet been having?*When did your pet start experiencing problems?*Has your pet been lethargic?* Yes No Has your pet's water intake:* Increased Decreased Stayed the same Has your pet's appetite:* Increased Decreased Stayed the same My pet has:* Gained weight Lost Weight Stayed the same Is your pet taking any medications?*(It is very important we know ALL medications your pet may have received) Yes No Please list medications your pet is taking, dosage and when they were last given.Is your pet on heartworm medication?* Yes No What is the name of the heartworm medication? Is your pet on flea and tick preventative?* Yes No What is the name of the preventative? Are you requesting any medication refills at this visit?* Yes No What is the name of the medication? Is your pet vomiting?* Yes No Please describe color, contents and consistency.When was the last time your pet vomited? My pet has normal stool* Yes No My pet seems constipated* Yes No My pet started having diarrhea* Yes No When was the last time your pet had diarrhea and how many episodes have they had?* Please describe color, contents and consistency.*What brand of food do you normally feed your pet?* What treats or other things does your pet usually eat?*Has your pet had access to any other foods besides normal pet food?* Yes No Please specify what other foods your pet had access to.*Is your pet coughing or gagging?* Yes No Is anything being expelled?* Yes No Please describe what is being expelled and approximately how much.*Is your pet sneezing and/or having any discharge from the eyes or nose?* Yes No Please describe the consistency, color and amount of discharge.*My pet is:* Lame Sore Has been injured None of the above What do you think is bothering your pet?* This issue has:* Worsened Remained the same Improved some N/A This issue has:* Never happened before Has recently happened before Is an ongoing (chronic) problem N/A Does your pet have any pre-existing conditions which may or may not be contributing to today's concern?*Please describe in your own words what seems to be the problem or list any additional information we may need while seeing your pet today.* I am the owner/agent for described animal. I authorize and request an exam for my pet. I understand that sedation and/or pain medication will be provided if deemed necessary. I understand that Crossroads Animal Hospital will contact me after an exam and treatment(s) have been performed on my pet. I have an initial estimate of the predicted charges, and can be reached at the number below. Contact phone number for today:* If I cannot be reached at this number, I authorize the initial diagnostics, such as radiographs and/or blood-tests, if indicated for my pet. In addition, I authorize the initial treatment, such as fluid therapy and other supportive medication(s) to be started as indicated for my pet. By signing below, I authorize anesthesia, surgery, and medications if required for the treatment of an abscess, laceration, or other wound, if my pet is present for one of these problems. I understand and accept that when anesthesia is involved, there are always inherent risks, including death. CPR RELEASE By allowing the doctor(s) and staff at Crossroads Animal Hospital to perform CPR, there are additional charges for which the client will be responsible. CPR for the first 15 minutes averages $150. If an emergency arises, please:* DO perform CPR and other life saving measures. DO NOT perform CPR and other life saving measures. POLICIES Please check each box indicating that you understand the following policies. 1. Cancellation policy* We require 24-hour's notice for cancellation of any appointment or procedure.2. Late policy* If you are more than 5 minutes late to your scheduled appointment you will need to reschedule.3. Drop off appointments* Plan on your pet being discharged at 5:30pm. The DVM will call you once they have looked at your pet and come up with a treatment plan. This call may not happen until later in the afternoon.4. Prescription refills* Prescription refills require 48 business hours' notice. There is an additional fee for urgent refills needed immediately. In the event of a life-threatening emergency, we reserve the right to treat your animal. Indicate amount approved to be charged should your pet needs emergency services while here* I understand that payment is due when my pet is discharged. In some instances a deposit may be required after an estimate has been prepared and discussed. I accept financial responsibility for charges incurred for this pet. I am aware that I will be charged for Capstar or Comfortis if evidence of fleas is discovered on my pet today. If your pet is here for a standard appointment - please remain in the parking lot for the duration of your pet's appointment. Pets that remain with us after their appointment has ended will incur a medical admission fee.* I have read and acknowledged the above statement Client Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Δ In
