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Phone: (541) 896-0044

Text: (541) 896-0044

Email: eastlanevet@gmail.com

42755 McKenzie Hwy, Leaburg, OR 97489

Online Pharmacy *

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Limited Exam Appointment Questionnaire

Pet Name
Client Name
Date
Reason for visit:
1. Is your pet on flea, tick or heartworm medications? If yes, what brand?
2. Is your pet on any prescriptions or supplements?
3. What type of food is your pet eating?
4. Are there any concerns with your pets behavior or obedience?
Client questions:
1. Have you or anyone in your household been exposed to Covid-19 within the past 10 days?
- Yes
- No
If so, when?
2. Have you or anyone in your household had any respiratory illness within the past 10 days?
3. What is the best phone number to reach you at?
Is there anything else you’d like us to be aware of regarding your pet or yourself?
Which type of appointment would you prefer?
- Curbside (wait in your vehicle while our team provides care)
- In Person Appointment (accompany your pet into the examination room)
- Outdoor Gazebo

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East Lane Veterinary Hospital

Phone: (541) 896-0044

Text: (541) 896-0044

Address: 42755 McKenzie Hwy, Leaburg, OR 97489

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