Pet Resort Questionnaire Form - Erlanger Veterinary Hospital

Name *

First

Last

Pet's Name *

By checking this box, I understand that I am authorizing a veterinarian to perform an exam on my pet when required to receive vaccinations that the Erlanger Pet Resort is not authorized to administer (distemper/parvo, rabies, and any feline vaccines) *

I understand

By checking this box, I understand that a pet that is Boarding or in Daycare REQUIRES an annual Fecal Panel. This test will be performed during this stay if it is due. *

I understand

Reason for Veterinary Exam

Is your pet currently experiencing any problems with coughing, sneezing, vomiting or diarrhea?

Coughing
Sneezing
Vomiting
Diarrhea

Is your pet currently taking any medications? *

Yes
No

List questions or concerns for the doctor:

What is your pet's current diet?

An annual blood panel is recommended for dogs and cats. It will look at a Chemistry panel, CBC, Heartworm & Tick borne diseases in dogs, urinalysis and fecal (if available), and a thyroid level for pets over 6 years of age. While this service is recommended, it is NOT required for services at the Erlanger Pet Resort and Day Spa and additional charges will apply. Do you want this performed during this visit if your pet is due? *

Yes
No

Do you need any medications, heartworm, or flea & tick prevention refilled at this time? *

Yes
No

If so, list name and quantity needed

administer at additional

Contact Number

Contact Email *

*

What is 3+3?