Lighthouse Pet Clinic Pre-Appointment Check-in – Providing Quality, Compassionate Care Because Pets Are Family Too

Step 1 of 6 - Client Information

16%

Please complete this form for all non-surgical appointments.

Client Information

Your Name*

First Last

Phone*

Please provide a phone number to reach you during your pet's appointment.

Email*

Pet's Name*

Type of Pet*

Dog

Cat

Other

Tell us what type of pet you have*

Appointment Date*

MM slash DD slash YYYY

Appointment Time*

Hours

Minutes

AM/PM

Have you moved within the last year?*

Yes

Please update your address if you moved in the past 3 months.

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name and Best phone number for person who is accompanying your pet during the appointment:

Who will bring the patient to the appointment?*

I Will Bring the Patient

Spouse or Loved-one

Family Friend

Other Person

Name Person Bringing Pet

First Last

Phone Person Bringing Pet*

Any Concerns about Your Pet?

Please List Any Specific Concerns:*

Provide details on what's going on with your pet. Symptoms, anything your pet may have gotten into, how long this has been going on, etc. Any refill request? Share any concerns you have.

Any Coughing or Sneezing?*

Check any that apply

Coughing

Sneezing

Both Coughing & Sneezing

None

Any Vomiting or Diarrhea?*

Check any that apply

Vomiting

Diarrhea

Both Vomiting & Diarrhea

None

Vomiting or Diarrhea

What does it look like? How often?

Coughing Up Hairballs?*

Yes

Any Lameness, Limping, or Joint Concerns?*

Yes

Which Leg

Any Excessive Scratching or Chewing at Skin?*

Yes

Scratching or Chewing Skin Details

Is Your Pet Urinating Normally?*

Yes - Seems Normal

Litter Box Habits*

Peeing & Pooping Inside Box

Peeing & Pooping Outside Box

Peeing Inside Box BUT Pooping Outside Box

Pooping Inside Box BUT Peeing Outside Box

Has your cat been tested for feline leukemia?*

Yes

Unsure

Energy/Activity Level?*

Normal

Lethargic/Low-energy

Increased/Hyper

Diet & Nutrition

Any Diet Concerns?*

Do you have questions or concerns
about your pet's weight, eating or diet?

Yes

Appetite*

How is your pet's recent appetite?

Not Eating

Eating More Than Normal

Eating Less Than Normal

Normal - Excellent Eater

Normal - Average Eater

Normal - Picky Eater

Current Diet*

Select all that apply

Wet

Dry

Grain Free

Other

Questions or Concerns about Your Pet's Diet?

Food Brand Name(s)*

(Write 'Don't Know' if you cannot remember)

Amount of Food Per Meal?*

Tell us # cups/cans per meal (or other details)

Feeding Schedule*

How many times do you feed your pet per day?

Treats Given

List types of treats and/or brand of treat(s)

Amount of Daily Treats

How many treats do you give your pet each day?

Water Drinking*

How is your pet's water consumption?

Normal

Increased

Decreased

Water Consumption Details

Medications

On Heartworm Medication?

Yes, Year-round

Yes, Seasonally

Heartworm Name Brand

(Write ‘Don’t Know’ if you cannot remember)

On Flea or Tick Medication?*

Yes, Year-round

Yes, Seasonally

Flea/Tick Medication Name Brand

(Write ‘Don’t Know’ if you cannot remember)

On any other medication or supplements?*

Yes

List Drug Names

Pet Dental Care at Home

How do you care for your pet's teeth at home?

Lifestyle & Activities

Lifestyle:*

Check all that apply

Daycare

Boarding

Grooming

Dog Parks

Camping/Hiking

Running/Walking

Home Body

Any other pets at home?*

Yes

Other Pets in Home

Cat Lifestyle*

Indoor Only

Outdoor Only

Indoor & Outdoor

Travel (Recent or Planned)

Yes

Travel Details

Please tell us about any planned travel. Also, tell us about historical travel your pet has had.

Client Consent

We do our best to promote an enjoyable environment and try to win our patients over with treats (including Peanut Butter) and affection.

Peanut Allergies

Does anyone in your household have peanut allergies?

Yes

We will put an alert in your pet’s chart to never use peanut butter. Other food treats such as cheese or baby food are available.

Peanut Butter Treats*

May we give your pet any treats, including peanut butter?

Yes - Peanut Butter Treats Okay

No - Do Not Give Treats

Other Treats*

May we give your pet any treats, excluding peanut butter because you said someone in your household has peanut allergies?

Yes - Other Treats Okay, NO Peanut Butter

No - Do Not Give Treats

Consent*

I agree to the following:

By checking this box, I agree and consent to have the veterinarian(s) at Lighthouse Pet Clinic examine my pet and prepare a medical treatment plan and cost estimate for treatment. I understand that Lighthouse Pet Clinic will provide this treatment plan and cost estimate to me for my approval prior to providing treatment.

Digital Signature*

Please type your name