County Animal Hospital

Please complete before your appointment to help us keep your pet's record accurate and up to date.

1. CLIENT & PATIENT INFORMATION

Client name(s)

Best Phone Number

Email

Patient Name

Sex:

Spayed/Neutered

Color/Markings:

2. PLEASE CONFIRM OR UPDATE YOUR INFORMATION

Has your address, phone number, or email changed?

What food are you currently feeding your pet?

3. REASON FOR TODAY'S VISIT

Please describe your concerns and what you would most like us to address:

When did you first notice the concern? Is it getting better, worse, or staying the same?

4. CURRENT MEDICATIONS & SUPPLEMENTS (NOT PREVENTATIVES)

List all prescription medications, over-the-counter products, vitamins, and supplements. Include the strength, dose given, how often it is given, route if applicable, and last dose.

5. PREVENTION & MEDICAL HISTORY

Flea/tick prevention (product and last dose):

Heartworm prevention (product and last dose):

Vaccines or tests performed elsewhere since the last visit?

If yes, please provide copies of the records or ask the other clinic to send them to us. Clinic name / date / details (if known):

6. ADDITIONAL NOTES & PRIORITIES

Is there anything else you would like the veterinarian to know?

What are your top priorities for today's appointment?

7. CONFIRMATION

County Animal Hospital • Thank you for helping us care for your pet.

Date

Client/authorized representative signature

Sign above

I have provided the information above to the best of my knowledge.

VETERINARY PRE-VISIT QUESTIONNAIRE

County Animal Hospital

Review Us!

Get In Touch

County Animal Hospital