Client Name* First Last Pets Name*Type of Pet* Dog CatBreed*Approximate age*Date of Appointment* MM slash DD slash YYYY Time of Appointment* : Hours Minutes AMPM AM/PMWhat is the main reason for your pet’s visit?*What questions if any do you have for the doctor?*Please answer the questions below.What is your pet's current diet (food type, brand, how much you feed and how many times per day, plus any treats and quantity given)?*Have your pet’s eating habits changed?* No, they are eating normally YesPlease explain*Have your pet’s drinking habits changed?* No, they are eating normally YesPlease explain*Have your pet’s bathroom habits changed?* No, they are urinating and defecating normally YesPlease explain (accidents in the house, urinating outside the litter box, diarrhea, constipation, etc).*Is your pet vomiting?* No YesDescribe*Is your pet experiencing any coughing or sneezing?* No YesPlease explain (how often, for how long, after a certain activity, etc.)*Is your pet currently taking any medications, supplements, vitamins, herbal products, flea and/or heartworm preventions?* No YesPlease list the dosage/quantity you are giving for each.*Does your pet have any known allergies?* No YesPlease explain (what are they allergic to and what is the reaction?)*Has your pet ever had any reactions to injections or vaccines?* No YesPlease explain (which injections/vaccines and what is the reaction?)*Have you noticed any changes your pet’s activity level or their ability to move around?* No YesPlease explain*Is your pet showing signs of pain?* No. Not that I can tell. YesPlease explain*Have you noticed any changes in your pet’s personality (disorientation, vocalization, signs of aggression, etc) or sleep habits (sleeping more that normally, pacing or restlessness at night, etc)?* No YesPlease explain*Does your pet go to a groomer, boarding facility, dog park, dog/cat shows or day care?* No YesPlease explain*Does your pet travel with you?* No YesPlease explain*Is your pet currently on a wellness plan?* Yes NoHave you downloaded our app and are a member of our loyalty rewards program?* Yes NoDownload to start earning: https://funkstownvet.com/download-our-app/Would you like an estimate provided for services?* Yes NoIf you or a member of your family have recently tested Positive for COVID we ask that you contact us immediately to reschedule your appointment.* I understand the statement above.Once you have arrived in our parking lot, you will need to check-in from your vehicle to let us know that you have arrived. You can check-in through our FunkstownVet app or by visiting https://go.v2p.us/l/5IKg. You may also CALL 301-733-7579 or if you do not have a cell phone each door has a call box that you can speak directly with a member of our CSR team.* I understand the statement above.PhoneThis field is for validation purposes and should be left unchanged.Δ