Patient History Form Lots of love and attention will be given to your furry friend while they're in our care! Please fill this form out completely and accurately and please be able to answer your phone during this appointment. The more attention you pay to this form now, the more time your Vet can dedicate to consulting with you! Thank you! * Indicates required informationPet’s Name(Required)Primary Contact Name(Required) First Last Phone Number (please be prepared to answer calls while your pet's hanging out with us)(Required)COVID-19 Risk Assessment (recent* means within 14 days)(Required)Please read carefully and select the most accurate choice.I've had known contact with a person that has tested positive for coronavirus.I've had recent* fever or respiratory disease symptoms.None of the above. I've been a social distance warrior and I've got my face mask ready for this appointment.If you've had recent exposure or clinical signs associated with COVID-19, please be responsible and send someone else to drop-off and pick-up your pet or reschedule for a later date. This is extremely important for the safety of our staff and other clients. We greatly appreciate your honesty and empathy. We agree with your pet, you're the best.Chief Complaint / Reason for Visit(Required)Tell us what's going on. Here's your chance to tell us something that might help the doctor understand any potential medical issues.(Required)Nutrition is absolutely key to good health. What are you currently feeding? (the more detail the better! Including brand and amount)(Required)Does your pet get any non-prescription medications or supplements? If so, please list below.Which heartworm and flea preventives are you giving? When (approximately) was the most recent dose?(Required)Please list any and all prescription medications your pet is currently receiving (including dosage and when last given). Please click the green plus sign to add another medication. We know this can be a pain, but honestly it can be really important for us to know. If your pet is currently not receiving any prescription meds, please type "none".(Required)MedicationHourMinuteAM/PM Add RemoveAny history of adverse reactions to previous therapy or drugs?Please only click "Submit" once and do not leave this page! This may take a few seconds. From everyone at PAZ - Thank You!PhoneThis field is for validation purposes and should be left unchanged.
