Curbside / Exam History Form - Bristol County Veterinary Hospital

Client's Name *

First

Last

Email Address *

Patient's Name *

Patient's Species *

Dog
Cat
Other

If Other, please specify. *

Is this the first time we have seen your pet? *

Yes
No

What Veterinarian / Veterinary hospital previously cared for your pet? *

May we contact them for medical records? *

Yes
No

If not please upload a copy.

Medical Records

Click or drag files to this area to upload. You can upload up to 5 files.

How long have you had your pet and from where did you obtain your pet? *

Does your pet have any previous medical history we should be aware of (Allergies/ surgeries/ chronic medical conditions) *

Yes
No

If yes, please explain. *

Has your pet been vaccinated for rabies? *

Yes
No

Date of vaccination

Is your pet up to date on other vaccines? *

Yes
No

Please list.

Has your pet been tested for heartworm and tick-borne disease in the past year? *

Yes
No

Has your pet been tested for Feline Leukemia and Feline AIDS? *

Yes
No

Who will be bringing your pet in for the appointment? *

First

Last

What car will they be driving? *

(Color / Make/ Model)

Best Phone number for communicating with the Veterinarian and Technician during the appointment. *

May we communicate via text during the appointment? *

Yes
No

What brings your pet in today? What is the primary reason for today’s visit? *

Is there anything else you would like to discuss with the doctor?

Please complete the following questions about your pet:

1. Does your pet have pet insurance? *

Yes
No

If yes – Provider? *

2. Describe your pets’ outdoor time. (Please check all that apply) *

Leash Walks
Fenced in Yard
Off Leash Walks
Indoor Potty

2. Describe your pets’ outdoor time. (Please check all that apply) *

Indoors Only
Indoors/ Outdoors
Outdoors Supervised

2. Does your pet go outside? *

Yes
No

If yes, please describe your pets’ outdoor activities.

3. Does your pet participate in: (check all that apply) *

If Other, please explain.

4. Has anything changed in or with your household? Example People/Pets come or gone, construction, moving, etc. *

Yes
No

Please explain.

5. Does your pet take any medications?

Yes
No

If so, please list including dosage.

6. Does your pet take any supplements?

Yes
No

If so, please list including dosage.

7. Does your pet need any refills on Medications/ Supplements / Prescription Diets?

Yes
No

If so, please specify.

8. Is your pet on Heartworm Prevention? *

If Other, please specify. *

9. Does your pet receive heartworm prevention year-round?

Yes
No

10. Is your pet on Flea and Tick Prevention? *

If Other, please specify. *

11. Does your pet receive flea and tick prevention year-round?

Yes
No

12. Please describe your pets diet including the type and amount of food they eat, including any treats or human food.

13. Has your pet or is your pet currently experiencing any of the following? (please check all that apply and describe)

Please describe Coughing/Sneezing/Wheezing

Please describe Vomiting / Diarrhea

Please describe Seizures, fainting or dizziness

Please describe Pain/ stiffness / lameness/ limping

Please describe Change in activity level - Lethargy/tiredness or Increased activity

Please describe Poor appetite / Weight loss

Please describe Increased thirst / Increased urination or accidents

Please describe Skin issues / Itching / Rash / lump or bumps

Please describe Eye issues

Please describe Ear issues

Please describe Dental issues

14. What vaccinations does your pet receive? If you have questions or are unsure, you can skip this question. (Please check all that apply)

Rabies
Rabies Purevax
Distemper (FVRCP)
Leukemia

15. Does your pet need any additional services today?

Nail trim
Ear cleaning
Anal gland expression
Sanitary clip

Is there anything else you would like to share with us about your pet?

Client Signature *

Check-in for your pet’s VIP curbside pick-up!

Please complete the following questions about your pet:

ADDRESS

TEMPORARY HOURS

CONTACT

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