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Telemedicine Client/Patient Information Form

Please complete the following information so that we can best assist you with your pet’s telemedicine consultation.
Pet Owner Name
Street Address
Zip Code
Primary Telephone
Email Address
Pet's Name
Pet's Species
If other, please specify your pet's species.
Pet's Sex
Pet's' Age (Years)
Pet's Weight (pounds)
Is your pet indoor, outdoor, or both?
Is this pet a current patient at Crossroads Animal Hospital?
Please briefly explain your pet's current problem (3 lines max)
When was the last time your pet ate food and drank water?
Within the last two weeks, has your animal displayed any of the following? (Check all that apply)
Has your pet ever had a seizure?
If yes, please explain
If your pet is an intact female, when was her last heat cycle?
Is your animal pregnant or nursing?
Within the last two weeks, are you aware of any change in your pet’s (check all that apply):
Are you aware of your pet ever having a history of previous health problems or injuries? (Check all that apply)
Please explain (3 lines max)
Has your pet ever had surgery before?
Please explain (3 lines max)
Are there any known reactions to vaccinations, drugs, or medications? If yes, please explain.
If yes, please explain (3 lines max)
Please list any medication (prescription or over the counter) your animal has taken in the past month and why.
Is your pet on flea and/or tick control?
If yes, what product was used and when was it last done?
Is your pet on monthly heartworm prevention?
To your knowledge, is your pet up to date on routine vaccinations?