Sick Visit

Client Name*

First Last

Pets Name*

Type of Pet*

Dog
Cat

Breed*

Approximate age*

Date of Appointment*

Time of Appointment*

:

What 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
Yes

Please explain*

Have your pet’s drinking habits changed?*

No, they are eating normally
Yes

Please explain*

Have your pet’s bathroom habits changed?*

No, they are urinating and defecating normally
Yes

Please explain (accidents in the house, urinating outside the litter box, diarrhea, constipation, etc).*

Is your pet vomiting?*

No
Yes

Describe*

Is your pet experiencing any coughing or sneezing?*

No
Yes

Please 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
Yes

Please list the dosage/quantity you are giving for each.*

Does your pet have any known allergies?*

No
Yes

Please explain (what are they allergic to and what is the reaction?)*

Has your pet ever had any reactions to injections or vaccines?*

No
Yes

Please 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
Yes

Please explain*

Is your pet showing signs of pain?*

No. Not that I can tell.
Yes

Please 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
Yes

Please explain*

Does your pet go to a groomer, boarding facility, dog park, dog/cat shows or day care?*

No
Yes

Please explain*

Does your pet travel with you?*

No
Yes

Please explain*

Is your pet currently on a wellness plan?*

Yes
No

Have you downloaded our app and are a member of our loyalty rewards program?*

Yes
No

Download to start earning: https://funkstownvet.com/download-our-app/

Would you like an estimate provided for services?*

Yes
No

If 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.

Phone

This field is for validation purposes and should be left unchanged.