Kitten's First Visit Carlson

Kitten's First Visit Form
We thank you for helping us give you the best service possible by completing this form within 24 hours of receiving.

PLEASE BE ADVISED: We are currently ONLY offering curbside service. WE REQUIRE ALL PATIENTS TO ARRIVE WITH A LEASH/COLLAR OR CARRIER. When you arrive for your appointment, please call and we will give you further instructions. Due to the high level of calls, you may experience longer hold times. We are doing our best to get to you as quickly as possible and appreciate your patience and understanding during this time.
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 so, 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
Phone Number To Contact You During Your Appointment *
Please enter a valid phone number.
Important Pet Information
Your Pet's Name *
Please list any concerns you would like us to address during your visit: *
If not applicable, please write none in the box
PLEASE SEND ANY RECORDS UPON ADOPTION TO OUR EMAIL: carlsonanimalhospitals@gmail.com

PLEASE BRING A FRESH FECAL SAMPLE TO YOUR APPOINTMENT
Please list any additional services you would like to request during your appointment, in the box below (i.e. nail trims, anal sac expression, ear cleaning etc.) *
While we always try our best to fit in any requested services but please be aware, performing additional services will ultimately depend on appointment times and staff availability. If not applicable, please write none in the box
Appetite and Diet
Is your pet's appetite *

Normal Increased Decreased
Is your pet's water intake *

Normal Increased Decreased
What brand and types of food does your pet eat? (canned/dry) *
What is the amount fed per meal, and frequency of meals? *
Gastrointestinal Health
Is your pet experiencing any vomiting? Please specify: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Is your pet experiencing any diarrhea? Please specify: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Respiratory Health
Is your pet experiencing any coughing? Please specify: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Is your pet experiencing any sneezing? Please specify: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Sensory Health
Is your pet experiencing any eye problems? Please specify: *
(date of onset, symptoms, which eye, discharge, color etc) If not applicable, please write none in the box
Is your pet experiencing any ear problems? Please specify: *
(date of onset, symptoms, which eye, discharge, color etc) If not applicable, please write none in the box
Is your pet experiencing any skin problems? Please specify: *
(date of onset, location, symptoms) If not applicable, please write none in the box
Activity and Balance
Is your pet experiencing any mobility issues? Please specify: *
(date of onset, symptoms observed etc) If not applicable, please write none in the box
Is your pet's activity level *

Normal Increased Decreased
Lifestyle and Preventatives
What brand of heartworm preventative does your pet receive (if any)? *
Does your pet receive this: *

Year-round Seasonally N/A
What brand of flea/tick preventative does your pet receive (if any)? *
Does your pet receive this: *

Year-round Seasonally N/A
Does your pet spend most of it's time: *

Indoors Outdoors Both
Medication and Refills
Please list any medications that your pet is currently on (include name, strength, dose, and frequency): *
If not applicable, please write none in the box
Please list any refills needed for medications, preventatives or prescription food here *
If not applicable, please write none in the box
CANCELATION POLICY

While we do understand emergencies and other scheduling conflicts can happen and are sometimes unavoidable, we request a 24-hour notice to change or cancel an appointment. After two missed or canceled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.

Thank you for completing this questionnaire. If you have any questions please call us 708.383.3606
Should be Empty:

Kitten's First Visit Form

COVID Screening Questions

Client Information

Important Pet Information