Curbside History Form Please have this form completed before coming to the hospital. Your pet will be brought into the hospital by a team member, the doctor will do an exam and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. As we have a limited number of phone lines, you may receive a phone call from a blocked or private number. Payment of services will be curbside as well, and expected after the visit is complete.Please call our office once you have arrived: 913-825-3330Please let us know where you have parked, the make, color and model of your car.Please have your pet on a leash or in a carrier before we come to the carName*Pet's Name*Cell phone where you can be reached*Alternative phone number (optional)Briefly describe the reason your pet is here for an exam, such as ear infection, sick, limping, etc.*Please answer all questions below regardless of why your pet is here.Has your pet had any coughing?*YesNoHas your pet had any sneezing*YesNoDoes your pet have any nasal discharge?*YesNoIf yes, what color and which nostril(s)?Has your pet been vomiting?*YesNoIf your pet has been vomiting when was the last time and describe the vomitHas your pet had diarrhea?*YesNoWhen was the last time you saw your pet's bowel movement and what did it look like?Has your pet been drinking more?*YesNoHas your pet been urinating more?*YesNoIf your pet's urine appears abnormal, please describe:Has your pet’s appetite changed?*YesNoif so describe howAny change in diet?*YesNoIf yes, when and what did you change?Is your pet lethargic (not active)?*YesNoIf yes, how long?Is your pet here because it is limping?*YesNoIf so which leg and how long?Please list all medications your pet is on and when they were last given:Does your pet have a problem with one or both of its eyes?*YesNoWhich eye, describe any drainage or symptoms.Does your pet have a problem with one or both of its ears?*YesNoWhich ear, describe any discharge or symptoms.Do you have a concern with your pet’s teeth?*YesNoIf yes, describe.Please use this space to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.NameThis field is for validation purposes and should be left unchanged.