Owner Name(Required)

First Last

Email(Required)

Phone(Required)

Pet Name(Required)

Breed(Required)

Dog

Cat

Age(Required)

Primary Care Veterinarian

Gender(Required)

Male

Female

Spayed/Neutered(Required)

Yes

How long have you owned your pet?(Required)

How did you obtain your pet?(Required)

What are your main concerns for your pet's health? What symptoms are you seeing at home that worry you?(Required)

How long have these concerns been present?(Required)

Does your pet spend time primarily indoors, outdoors, or both(Required)

Do you have a multiple pet household(Required)

Yes

Is your pet having vomiting or diarrhea? If yes, please describe the appearance (blood, mucus, bile, consistency, etc) and frequency

Is your pet having breathing difficulties or coughing? If yes, please describe (panting, noisy breathing, wet or honking cough, etc)

Is your pet having sneezing or nasal discharge? If yes, please describe the frequency and appearance

What diet does your pet eat (brand and type, main ingredients if known)(Required)

Is your pet's appetite normal? If not, please describe whether appetite is increased or decreased

Is your pet drinking a normal amount of water? If not, please describe whether the water intake is increased or decreased

Is your pet urinating normal volumes? If not, please describe whether urine volume is increased or decreased

Is your pet urinating more frequently?(Required)

Is your pet having any difficult or painful urinations?(Required)

Has your pet lost weight recently?(Required)

Does your pet have a normal activity level? If not, please describe

Is your pet's behaviour normal? If not, please describe

Have you noted any abnormal bleeding? (from the gums or nose, in the urine/feces, etc)(Required)

Is your pet up-to-date on routine vaccinations?(Required)

Does you pet receive monthly heartworm and flea preventatives?(Required)

Have you seen a tick attached to your pet in the past six months?(Required)

What medications and/or supplements (including herbs and vitamins) are you giving your pet? If available, please provide the doses(Required)

Does your pet have any previously diagnosed medical problems?(Required)

CAPTCHA