Re-Check Exam Questionnaire Carlson

Re-Check Exam Questionnaire
Thank you for filling out our pre-exam questionnaire. This helps us give you the best possible service!
Due to the high level of calls and patients we are taking in, you may experience longer wait times. We are doing our best to get to you as quickly as possible and appreciate your patience and understanding during this time.

Please be aware we are only offering curbside service at this time. Call when you arrive in the parking lot and a receptionist will give you further instructions on our protocol. We require you to sanitize your pet's carrier, leash, collar or harness prior to arriving and ask you to wear your mask when interacting with staff.
COVID Screening Questions:
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, fever, cough, chills, body aches, shortness of breath, loss of smell or taste? *

Yes No
Have you or anyone in your household been tested positive for COVID-19? *

Yes No
Have you or anyone in your household traveled outside the state or US in the past 21 days? *

Yes No
If yes, where did you travel to?
IF YOU ANSWERED YES TO ANY OF THESE QUESTIONS, PLEASE CALL OUR HOSPITAL TO DISCUSS OUR PROTOCOL.
Client Information
Owner First And Last Name On Account *

Owner First Name Owner Last Name
Best Phone Number To Reach You During The Appointment *
Please enter a valid phone number.
Patient Wellness Questionnaire
Your Pet's Name: *
Please list any concerns you would like the doctor to address during the appointment: *
If not applicable, please write none in the box
Have there been any improvements since your last visit? Please list below: *
If not applicable, please write none in the box
Is your pet tolerating medicines prescribed well? If not, please explain: *
If not applicable, please write none in the box
If your pet needs any refills on medications or preventatives, please list below: (include name, strength, dosage, and frequency): *
If not applicable, please write none in the box
Are there any other concerns you'd like to address? Please list below: *
If not applicable, please write none in the box
CANCELATION POLICY

We realize that emergencies and other scheduling conflicts can happen and are sometimes unavoidable. Please provide Carlson Animal Hospital with 24-hour notice to change or cancel an appointment. After two missed or cancelled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.
Should be Empty:

Re-Check Exam Questionnaire

COVID Screening Questions:

Client Information

Patient Wellness Questionnaire