Pre-Visit Questionnaire 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: 913-825-3330 Please 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 car Today's Date* MM slash DD slash YYYY Name* 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.Tell us all the foods and treats your pet eats.What medications and supplements does your pet take?Has your pet had any coughing?* Yes No Has your pet had any sneezing* Yes No Does your pet have any nasal discharge?* Yes No If yes, what color and which nostril(s)? Has your pet been vomiting?* Yes No If your pet has been vomiting when was the last time and describe the vomit Has your pet had diarrhea?* Yes No When was the last time you saw your pet's bowel movement and what did it look like? Has your pet been drinking more?* Yes No Has your pet been urinating more?* Yes No If your pet's urine appears abnormal, please describe:Has your pet’s appetite changed?* Yes No if so describe how Any change in diet?* Yes No If yes, when and what did you change? Is your pet lethargic (not active)?* Yes No If yes, how long? Is your pet here because it is limping?* Yes No If 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?* Yes No Which eye, describe any drainage or symptoms. Does your pet have a problem with one or both of its ears?* Yes No Which ear, describe any discharge or symptoms. Do you have a concern with your pet’s teeth?* Yes No If 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.