Patient Exam History Form | Old Mill Veterinary Hospital

Is this an in-person appointment or curbside?*

In-Person Appointment

Curbside

Date*

Curbside Appointment – Please arrive 10 minutes before your appointment time.

Park – Please let us know where you have parked, the make, color and model of your car.

Notifying us of your arrival – Please call our office once you have arrived.

Pet Prepared – Please have your pet on a leash or in a carrier before we come to the car.

Email: [email protected]
FAX: 703-779-7440
Questions? Call: 703-779-2903

If requested, please have a fecal and/or urine sample available

Please check here if you require a printed treatment plan with cost estimate

Yes, I require a printed treatment plan with cost estimate

Owner's First Name*

Owner's Last Name*

Pet's Name*

Best Phone Number to Contact You*

Best Email to Contact You*

Please have this form completed before coming to the hospital. Your pet will be brought into the hospital by a team member the doctor will do an exam and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment of services will be curbside as well, and expected after the visit is complete.

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.*

Has your pet had any coughing?*

Yes

Has your pet had any sneezing?*

Yes

Does your pet have any nasal discharge?*

Yes

If yes, what color and which nostril(s)?*

Has your pet been vomiting?*

Yes

If your pet has been vomiting, when was the last time and describe the vomit?*

Has your pet had diarrhea?*

Yes

Does your pet's stool look normal in color? Is it black or bloody?*

Yes

Black

Bloody

Has your pet been drinking more?*

Yes

Has your pet been urinating more?*

Yes

Have you seen your pet's urine?*

Yes

If so, what was the color and amount?*

Has your pet's appetite changed?*

Yes

If so, please describe how*

When was the last time you saw a bowel movement and what did it look like?*

Any change in diet?*

Yes

If so, when and what did you change?*

Is your pet lethargic?*

Yes

If so, how long?*

Is your pet here because it is limping?*

Yes

If so, which leg and how long?*

Please list all medications your pet is on and when they were last given*

Has your pet cried out?*

Yes

If so, what was your pet doing when this occurred?*

Does your pet have a problem with one or both of its eyes?*

Yes

If so, which eye? Describe any drainage or symptoms.*

Does your pet have a problem with one or both of its ears?*

Yes

If so, which ear? Describe any discharge or symptoms.*

Do you have a concern with your pet's teeth?*

Yes

If yes, please describe*

Are there any new lumps or bumps you have found?*

Yes

If so, where are they and how long have they been present?*

Please use this area to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.

Signature*

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