Curbside Care Medical History Form

To provide safe and efficient curbside service, we kindly ask all clients to complete a Curbside Care Medical History Form before their pet’s visit. This helps our veterinary team better understand your concerns and prepare for your pet’s needs in advance.

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Date / Time

Owner's Name

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Day-Time Phone

Evening Phone

Mobile Phone

Pet Information

Pet's Name

Species

Breed (if known)

Sex

Color

Date of Birth or Age (if known)

Pet Health - Reason for Visit

Describe your concern

How long has this been going on?

Days/Weeks/Months

What are you currently feeding the pet?

food/treats

How is their appetitie?

poor/good/excellent

has Phone Address

Are you currently giving any medications or supplements?

Any coughing or sneezing?

Any vomiting or diarrhea?

Have they gotten into anything? Eaten anything unusual?

Is your pet indoors only? (Cats)

Any environmental changes?

Describe their behavior

lethargic/normal/hyperactive

Any changes to thirst?

increased/normal/decreased

Any changes to urination?

increased/normal/decreased

How are their bowel movements?

normal/abnormal

When was their last bowel movement

Curbside Care Medical History Form

Owner's Name

Pet Information

Pet Health - Reason for Visit

Services

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