ARLINGTON CAT CLINIC – Pre-Exam Questionnaire

1

What day and time is your appointment?* This field is required.

Appointment Date

Appointment Time

2

Owner Details

Owner First Name

Owner Last Name

Cell Phone

Patient Name

Email Address

Services Requested Today (please list)

Indoor/ Outdoor Supervised/ Outdoor Unsupervised

3

Owner Date of Birth* This field is required.We occasionally prescribe controlled substances and must have a humans date of birth on file for our feline patients.

4

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

County

5

Is your cat currently taking any medications, flea preventive, heartworm preventive or food supplements?

Type

Dose

Type

Dose

6

Pet's Diet Please make sure to complete this section before moving forward with the form.

Number of cats in household

Other pets

Diet: Brand dry

Amount/day

Brand canned

Amount/day

Table scraps

Treats

7

Is your cat Declawed?* This field is required.

Declawed (Front)

Declawed (All Four Paws)

Not Declawed

8

Any changes in your cat’s attitude or activity level?* This field is required.

Yes

No

9

If Yes, please specify

10

Any changes in how much your cat eats or drinks?* This field is required.

Yes

No

11

If Yes, please specify

12

Any problems with coughing, sneezing, or breathing?* This field is required.

Yes

No

13

If Yes, please specify

14

Any problems with the eyes, ears or nose?* This field is required.

Yes

No

15

If Yes, please specify

16

Any hair loss, sores, lumps, scratching or other skin problems?* This field is required.

Yes

No

17

If Yes, please specify

18

Any problems with vomiting?* This field is required.

Yes

No

19

If Yes, please specify

20

Any problems with diarrhea?* This field is required.

Yes

No

21

If Yes, please specify

22

Any problems with hard or dry stools?* This field is required.

Yes

No

23

If Yes, please specify

24

Does your cat ever urinate or defecate outside the litter box?* This field is required.

Yes

No

25

If Yes, please specify

26

Does your cat have a hard time jumping or climbing stairs?* This field is required.

Yes

No

27

If Yes, please specify

28

Any changes in the amount of urine or stool?* This field is required.

Yes

No

29

If Yes, please specify

30

Do you have pet insurance?

Insurance Company

Do you have any questions or concerns today that are not covered above?

31

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED

In admitting/presenting my pet(s) for diagnostics, treatment, surgery, I authorize the doctors of Arlington Cat Clinic, LTD and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for hospitalization and surgeries. No guarantee or assurance can be made as to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment if possible. I agree to pay the Arlington Cat Clinic, LTD at the time services are rendered. If the account goes delinquent; no payment in 30 days, the account will be assessed a 2.00% billing fee on the outstanding balance(24% yearly). I further agree if the account is transferred to collections, I will be responsible for all costs necessary to collect this balance including collection fees, attorney fees, court costs, and filing fees. If a check is returned non-sufficient funds, a minimum charge of $25.00 will be added to the amount owed.

32

Signature* This field is required.Please Type your Full Name

33

I am in this vehicle

( Please list model and color )

34

Best phone number for today's appointment

( The veterinarian and technician will use this number to communicate with you through the appointment. )

35

Primary reason for Appointment / Concern ( Please be as detailed as possible. )

36

List Medications your pet is currently taking

37

Do you need refills of any of these Medications?

YESNO

38

If Yes, please specify

39

Do you need refills on any prescription pet food?

YESNO

40

If Yes, please specify