Limited Exam Appointment Questionnaire Pet NameClient NameDate MM slash DD slash YYYY 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
