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New Client Special*: 50% off first exam fee.

Mondays belong to the Seniors! Starting April 1st, clients over the age of 55 will receive a 10% discount on any appointments scheduled on Mondays.

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Please fill out this form before your visit.

Canine Wellness Form

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Name *

First

Last

Phone *

I consent to receive SMS text messages from Fox and Friends Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Email *

Pet's Name *

Any new medical concerns we should know about?

What kind of food are you feeding? How much are you feeding and how many times a day? *

Are there any changes in their eating or drinking habits? *

Is your pet have any of the following issues: *

Vomiting
Diarrhea
Sneezing
Coughing
Eye Discharge
Nasal Discharge
Head Shaking
Ear Scratching
None of the above

Is there a particular time of day/night the vomiting occurs? *

Please describe the diarrhea (bloody, mucoid, watery, amount, normal or abnormal color, consistency, etc.) *

Is it a productive cough, and if yes, what does the pet cough up? *

When did the eye problem start? *

Does there seem to be any pain (i.e. squinting)? *

Is the pet rubbing at eye(s) a lot? *

Any other pets or people affected in the house? *

Is there a known trauma? *

Have you tried any treatments at home? *

Are the ears painful? *

Do you clean the ears on a regular basis? *

What do you use? *

Is the pet scratching or shaking its head a lot? *

Have you tried any treatments at home? *

Does your pet have a recent history of swimming, bathing or in a moist environment? *

Has the pet's appetite changed? *

Are there any difficulties swallowing? *

Is there any sneezing, nasal discharge or bleeding? *

If discharge is present, is it from one or both nostrils? *

Left nostril
Right nostril
Both

Is there any time of day or situation where the symptoms are worse? *

Any recent changes in their diet? *

Did you recently open a new bag of food? *

Did you recently buy new treats/rawhides/bones? *

Is your pet vomiting food or phlegm/bile? *

Does your pet gobble its food? *

How long after eating does your pet vomit? *

Is there any history of recently eating garbage/table scraps/toys/strings? *

Have you tried a bland diet? *

Has there been a change in environment, boarding or other stress? *

Has your bet been recently boarded, dog parks or around other/new pets? *

Is there a time of day or situation when the cough is more prominent? *

Do we have permission to do diagnostics that the doctor deems necessary, such as bloodwork and x-rays? *

Do we have permission to do diagnostics that the doctor deems necessary, such as a fecal test and bloodwork? *

Do we have consent to do diagnostics, such as radiographs, if the doctor deems it necessary? *

Do we have consent to do diagnostics, such as an ear cytology, if the doctor deems it necessary? *

Do we have consent to do diagnostics, such as an eye stain or Schirmer test, if the doctor deems it necessary? *

How is your pet's activity level? *

Are they housebroken? *

Any changes in urination or defecation? *

Urination
Defecation
None

When did the urinary issues start? *

Is your pet unable to urinate or straining with no success? *

Is the urine a normal color, amount, and frequency? *

Does your pet have control over urination, or does it happen without them knowing it? *

Has there been a change in the diet? *

Are any of your pet's urination habits different (ie out of the box, in the house)? *

Do we have permission to do diagnostics that the doctor deems necessary, such as bloodwork and urinalysis? *

How many pets are in the household? *

Are they currently on heartworm prevention? *

Are they currently on flea/tick medication? *

Are they currently on any medications, including supplements? *

If yes, please list *

Any lumps noted? *

If yes, please explain *

Are there any behavioral concerns?

Are they having trouble with joints (trouble jumping/climbing stairs/etc)? *

Are they having trouble with their hearing? *

*Are they having trouble with their vision? *

Other comments

Have a question?

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Email *

Phone

I consent to receive SMS text messages from Fox and Friends Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

How can we help you? *

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