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. 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

Contact Number

Contact Email *