*Name

*Address

City, State, Zip Code

*Phone

Alternative Phone

*Email:

*Pet's Name

*Age

Color

*Breed

If mixed, about how much does your pet weigh?

Sex

Spayed/neutered?

Species

*We have a few questions about coronavirus risk as this impacts precautions we take while handling pets.

1. Has anyone in your household had flu-like symptoms, been exposed to coronavirus, been under quarantine for coronavirus, or been diagnosed with coronavirus during the past two weeks? IF THE ANSWER TO THIS QUESTION IS YES - DO NOT CONTINUE WITH THE FORM. INSTEAD, CALL US AT (864) 972-9994 FOR ADVICE ON HOW TO PROCEED. DO NOT ARRIVE FOR YOUR APPOINTMENT WITHOUT SPEAKING TO US FIRST.

Rabies vaccine last given

DHPP or RCP vaccine last given

Lepto or Leukemia last given

Bordetella last given

Has your pet ever had a vaccine reaction?

If so, describe

*On heartworm prevention?

What kind?

*On flea prevention?

What kind?

*What food does your pet eat?

*Any supplements/people food

*Has your pet had any medical concerns in the past / any history of illness? If so, please explain:

*Does your pet spend time outdoors where wildlife live (for instance access to creeks, lakes, roaming outdoors, camping)

*Does your pet go to a groomer or boarding facility or do you work or volunteer in a grooming/boarding/kennel facility?

*Are there any people in contact with this pet who are immunosuppressed?

*Is your pet friendly with strangers? If no, provide details of what sort of situations he/she is not friendly in

What current medications and/or supplements is your pet on? Please list the amount and time you give each day.

We recommend all pets both young and old have at least annual bloodwork ran to obtain a baseline of each pet's normal levels of organ function. Would you like us to run bloodwork on your pet today?

*Primary Concern Today

Duration of symptoms

Getting better/worse?

*How is your pet feeling?

*Appetite

*Drinking/urination

*Any vomiting?

*Any diarrhea?

*Any coughing, sneezing, or nasal discharge in the past two weeks? If yes, describe

*Has your pet had a similar problem in the past?

Please list all the medications you are currently giving your pet and how frequently you are giving them. Please list even if you were prescribed them by us as we want to confirm your pet is still receiving them. Please note if your pet has missed any doses within the past week and when it was missed. List the times you last gave each medication. (example: Furosemide 12.5 mg 1 tab once daily, last given at 8am today, one dose missed yesterday morning)

*Is there anything else we need to know?

Please note: We will do an examination and basic testing/medications (such as giving pain meds to a painful pet) and then Dr. Jordan will give you a call to discuss the treatment plan. Typically the cost of the initial exam, tests, and meds is $100-250. If it is over $250, we will call you to discuss prior to performing tests/treatments. Once we have completed tests and treatments, we will call you and set up a pick up time. We will take payment at that point over the phone. Do you have any questions or concerns?

Do you have any other pets (that you haven’t told us about) that are NOT patients of Crossroads Animal Hospital? If yes, what is their age, breed, and current vet?