Pet Name* Owners First and Last Name* Date and Time of Appointment Is your pet indoor or outdoor? Is your pet eating and drinking normally? Diet type, amount, frequency, table food, etc: Any vomiting or diarrhea? Any changes in bathroom habits? Are they coughing or sneezing:? Any skin issues or changes? Any concerns regarding eyes, ears, nose or muzzle? Does your pet have any stiffness or lameness or other pain? Any Behavioral Changes or history of seizure? If you answered yes to any of the questions above, please describe the symptoms you are seeing and how long has this been going on? Any risk of coming into contact with Kennel Cough (dogs only)? Has your pet traveled out of the area? when? where? Please list current Medications, supplements, and prevention Any history of reaction to medications? Other Information the Dr may need to know? May we have permission to take your pets photo to share with you and on our social media? EmailThis field is for validation purposes and should be left unchanged.