Annual Appointment Form

Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Species *

Dog
Cat

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Who should we contact to make medical decisions today? *

First

Last

At what number can they be reached today? *

We will call you for a curbside visit. Do you have an iPhone for a video call or an Android for a video exam? *

iPhone
Android
Neither

If the infection rates allow it, would you prefer an in-person visit? *

Yes
No

**Please bring your proof of vaccination or Excelsior Pass with you to the visit. We ask that only one fully vaccinated adult be present at your pet’s exam since our exam rooms are too small to accommodate many people.**

Reason for visit: (check all that apply) *

Annual Physical
Fecal/intestinal parasite screen
Deworming treatment
Other

If other, please specify *

Do you want an Ellie Profile? We can draw blood on your well pet with your other blood tests today and send it off. This simple blood test gives us powerful information and then rates the health of your pet on a score from 1-100! This is the most comprehensive and detailed bloodwork in a report you can understand! *

Yes
No

Dog Vaccines

Feline Vaccines

FVRCP/Distemper
Rabies
Feline Leukemia (FeLV)

Other procedures: (All procedures at additional cost)

Is your pet on a wellness plan? (If you leave them for the day or come 30 min early, we will do thermal imaging, AI ECG and a stance analyzer for free) *

Yes
No

Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply)

What is the severity of itching? (1 being minor, 10 being severe)

Selected Value: 1

If 8-10, please bring a stool sample from today.

Has this happened before? *

Yes
No

If yes, when? *

Has your pet been treated before? *

Yes
No

What was used and how did it do? *

Have you seen any fleas in the past month? *

Yes
No

What and when was the last flea medicine given? *

Are other animals/humans affected in the household? *

Yes
No

What does your pet eat? What do you share off your plate? *

How many times a day does your pet poop? *

How old was your pet when this started? *

Does your pet have any of the following? *

Lethargy
Weight gain
Dry coat
None of the above

Are the ears involved? *

Yes
No

Do you know if any of the siblings or parents experienced ear or skin problems? Do you know how it was treated? *

How severe is the foot licking? (1 being minor, 10 being severe)

Selected Value: 1

What paw(s) is your pet licking? *

Where are the skin masses located?

If Other, please explain:

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

Yes
No

If Yes, please elaborate: *

What brand and type of food do you feed your pet?

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

How much is given during each feeding and how many feedings per day?

Do you have insurance for your pet? *

Yes
No

If yes, what insurance?

Do you give your pet heartworm or flea/tick preventative? *

Yes
No

Please specify product(s) and date last given *

Do you wish to take home flea/tick or heartworm prevention today? *

Yes
No

Flea/Tick/HW prevention:

What percentage of time does your pet spend outside?

Have you seen any fleas or ticks on your pet? *

Yes
No

Please specify - fleas or ticks?

Do you have other pets? *

Yes
No

Are they currently vaccinated and on heartworm and flea prevention? *

Yes
No

Does your pet come into contact with other dogs? Please check all that apply *

If Other, please explain:

Is your pet on any medications? *

Yes
No

If Yes, please list all medications (prescribed or over the counter) and the time of last administration:

Was your pet last seen by a veterinarian at Guardian Animal Medical Center? *

Yes
No

Is your pet’s Rabies vaccine up to date? *

Yes
No

When is the last time your pet was seen by a veterinarian? *

Who was your pet’s previous veterinary clinic? *

Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Guardian Animal Medical Center authorization to treat as discussed above. *

I have read and agree

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days? *

Yes
No

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Who experienced these symptoms?

Self
Someone else in the house
No symptoms

*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.

In-person visit: Please call or text our team when you arrive to check in. When the doctor is ready to examine your pet, a team member will escort you into the exam room. We ask that you remain seated during the exam and allow a trained patient handler to provide physical support to your pet. Wearing a mask is required. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we ask that you return to your vehicle while the doctor and nurses complete the services discussed (such as bloodwork, x-rays, or other therapies). As with curbside visits, we will call or send a secure link for payment after the visit is complete and bring your pet back to you. This will allow for proper cleaning time between patients to keep all of our patients, clients, and team members as healthy as possible. *

I have read and understand.

Critter concierge: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or nurse will call you in your vehicle to discuss your pet’s exam and discuss recommended treatments or preventative measures. *

I have read and understand.

Day Admission Appointment: A day admission appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive. *

I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Yes
No

Please type your initials. *

Date *

We’ll be there when you need us.

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