If you will be bringing in more than 1 pet for your appointment, please fill out this form for each pet separately.

Patient Exam Questionnaire

  • COVID-19 NOTICE

    Our lobby remains closed to the public. We are operating as Curbside Service until further notice.When you arrive for your appointment, pull in to a numbered parking spot (when available) and call 704-541-7171 from your vehicle to let us know you have arrived.The technician will come out to your vehicle to transport your pet inside to the doctor, and the doctor will call you to discuss findings and go over any recommendations/services to be completed as well as discuss any questions or concerns you may have.We will collect payment over the phone (if we do not already have card information on file) and email you a receipt.The technician will bring your pet back out to your car.Please remain in your parking spot for the duration of the appointment unless otherwise discussed.Thank you for your time and understanding as we work to keep our employees and clients safe and healthy!
  • In the event all numbered spaces are already taken when you arrive.
  • :
  • Please be as detailed as possible.
  • If your pet is showing none or one of these signs below, please select appropriate option. If showing more than one of these signs, please select "My pet shows many of these signs."
  • If so, please let us know these important details:
    1. Exact name and dosage if applicable
    2. How much and how often you are administering?
  • If your pet is not currently on preventative, please type "None"
  • If your pet is not currently on preventative, please type "None"
  • Check your supply of heartworm/flea and tick preventatives, medications prescriptions, supplements, or anything else we can prepare for you!
  • For medications, please let us know these important details:
    1. Exact dosage
    2. Exact quantity
    3. How much and how often you are administering?
    4. Will you need any pills cut? *Per FDA, we can only cut up to 30 days worth at a time. For over 60 pills there is a convenience cutting fee of $6.00.
  • Groomer, Daycare/Boarding Facility, Dog Parks, etc.
  • If so, let us know here and where we can call to get that sent over.
  • If your pet is showing one of these signs below, please select. If showing more than one of these signs, please select "My pet shows many of these signs."
  • Select all that apply.
  • I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Piper Glen Animal Hospital has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Piper Glen Animal Hospital can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I voluntarily seek services provided by Piper Glen Animal Hospital and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Piper Glen Animal Hospital harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Piper Glen Animal Hospital. I understand that this release discharges Piper Glen Animal Hospital from any liability or claim that I, my heirs, or any personal representatives may have against the hospital with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Piper Glen Animal Hospital. This liability waiver and release extends to the hospital together with all owners, partners, and employees.