Owner Name *
First Last Today's Date: * Date of Appointment * Time of Appointment * Do you prefer In-Clinic or Curb-side service? *
STARTING JUNE 15 - Please keep in mind that if you elect to come in to the clinic for your pet’s visit as opposed to the curb-side option, you will still need to call us to let us know you have arrived. The doctor’s technician will come to your car and escort you into the building. Only 1 family member is allowed in with the patient and you MUST be wearing a mask. If you do not have one, one will be provided for you. Due to our exam room sizes and the inability to safely socially distance the 6 ft, the exam will be done with the doctor in our treatment area while you wait in the room. Once the exam is complete, the doctor will come to the room to speak with you about their findings, any recommendations, and to go over any questions or concerns you may have.
In-Clinic (Only available beginning June 15) Curb-side Best Phone Number During Visit * Confirm Email *
Confirm Address * Is the owner or anyone living in the home quarantined because of Covid-19, or pending a Covid-19 test, or showing any related symptoms? * Yes No Pet Name * Pet Species * Canine Feline Patient's Sex * Male Neutered Male Female Spayed Female Primary Reason for Appointment/Concerns
Please be as detailed as possible.
What type/brand of food does the patient eat? * How much/often is the patient fed daily? * Is the patient's diet Grain-Free? * Yes No Unsure How is the patient's appetite? * Normal Increased Decreased How is the patient's water intake/drinking? * Normal Increased Decreased How is the patient's urination? *
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."
No abnormal signs seen. Increased frequency Decreased frequency Straining to urinate Accidents in the house Leaking where resting Blood present Dark/Cloudy Foul odor present My pet shows many of these signs. Has your pet had any vomiting or diarrhea? * Yes, vomiting (multiple episodes) Yes, vomiting (single episode) Yes, diarrhea (multiple episodes) Yes, diarrhea (single episode) No GI symptoms present Has your pet had any coughing or sneezing? * Yes, coughing (multiple episodes) Yes, coughing (single episode) Yes, sneezing (multiple episodes) Yes, sneezing (single episode) No coughing or sneezing seen. Is your pet on any daily medications or supplements?
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? What brand of heartworm prevention does your pet currently take? *
If your pet is not currently on preventative, please type "None"
What brand of flea/tick prevention does your pet currently take? *
If your pet is not currently on preventative, please type "None"
Will you need any refills while you are visiting? *
Check your supply of heartworm/flea and tick preventatives, medications prescriptions, supplements, or anything else we can prepare for you!
Yes, I will need refills. No, I will not need refills. If you will need refills, let us know here!
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. How much time does your pet spend outdoors? * 0% - only if they escape 25% - just enough to take care of business. 50% - we like to take walks, visit dog parks and greenways, and have an active lifestyle. 100% - comes in only at night for shelter but loves being outside. List of places most visited (if applicable)
Groomer, Daycare/Boarding Facility, Dog Parks, etc.
Has your pet been to any different boarding facilities, grooming facilities, dog parks, daycares, or around other dogs socially within the last 3 weeks? * Yes No Has your pet had any vaccines or lab work updated anywhere else?
If so, let us know here and where we can call to get that sent over.
Has your pet shown any of these signs of allergies? * Licking/Chewing - paws Licking/Chewing - rear Licking/Chewing - groin Shaking head Scratching - ears Scratching - body My pet has many of these signs. No allergy signs seen at home. Has your pet shown any of these signs of allergies? * Licking/Chewing (paws, rear, groin, etc.) Shaking head Scratching (ears, body, etc.) My pet has many of these signs. No allergy signs seen at home. Has your pet shown any signs of joint pain? *
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."
None of these signs noticed at home. My pet shows many of these signs. Stiffness, lameness or difficulty getting up Trouble with stairs or getting on furniture Lethargy Reluctance to run, jump or play Weight gain Irritability or changes in behavior Pain when petted or touched Difficulty posturing to urinate/defecate Having accidents in the house Loss of muscle mass over the limbs/spine Has your pet ever had adverse reactions to any vaccines or medications? * Yes No If yes to the above question, please explain: Does your pet currently have a pet insurance policy? * Yes Not at this time If you already have your pet on a policy, please list which insurance company here: Any previous patient history we should be aware of? For In-Clinic visits: Would you prefer for your pet's services to be done in the exam room or in the treatment area? * **COVID-19 INFO** Due to our exam room sizes and the inability to safely socially distance the 6 ft, after June 15th, if a family member elects to come into the clinic with the patient, the exam will be done with the doctor in our treatment area while you wait in the room. Once the exam is complete, the doctor will come to the room to speak with you about their findings, any recommendations, and to go over any questions or concerns you may have. While we wish it wasn't, we understand the vet can be a scary place for patients and their families alike. We want you to know that we have your pet's best interest at heart when it comes to their experience at our hospital. There are times when providing services in the exam room is better for the patient, and times when it is best for the patient to be removed from the smaller area that can sometimes feel more crowded and threatening than helpful. We will be sure to monitor your pet's behavior and body language closely so that we can determine what will be the least stressful approach to provide the best quality care. If given the choice, what would you prefer? All patients will be taken to the treatment area to minimize the exposure of COVID-19 to staff members. How would you describe your pet's reaction to going to the veterinary hospital? * Eager and excited Neutral Reluctant Very scared Are there things that you or your pet did not like during past veterinary visits? * No issues/concerns Walking through the clinic / nervous or anxious / dog aggressive Being weighed / scared of scale Being handled by veterinary staff / scared / will bite Getting on the exam table / prefers to be on ground or in a lap Having a service/procedure done Feel free to elaborate on experience/behavior/preferences of patient in clinic here if answered yes to any of the above: Has your pet ever been prescribed a mild sedative medication to help with the visit to the veterinary hospital? If so, what was the name of the medication(s) and what kind of result did you experience? Does your pet seem less nervous around males or females?: * Prefers Females Prefers Males Does not seem to have a preference Is your pet food motivated to help reduce fear during procedures? * Yes! No, too fearful. I'm not sure. DO NOT GIVE TREATS! - PET OR HOUSEHOLD ALLERGIES How and where does your pet travel in the car? * Carrier/Crate Seatbelt Loose Does your pet show any reluctance to getting into/out of the carrier/car? * Yes No How does your pet behave in the car? * Relaxed Restless Trembling Barking Whining Pacing Panting Drooling Hiding Will run if given the opportunity
Select all that apply.
COVID-19 WAIVER FOR IN-CLINIC APPOINTMENTS *
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.