Senior Pet Pre-Visit Form

Senior Pet Pre-Visit Questionnaire

To make your pet’s veterinary experience as enjoyable and as stress-free as possible, it is important for us to understand your pets’ preferences and to identify any age-related concerns. Please take a moment to complete this questionnaire by answering the questions below to the best of your ability, please also complete the Osteoarthritis Pain Check List included. The information you provide will help us to adjust the care we provide to better serve the needs of your senior pet.

Complete the form.
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Name

Date

Pet Information

Please provide your pet's information

Fel

Other

M/N

F/S

Vaccinations (date last given)

Has your pet ever had a vaccine reaction:

Disease/Parasite Screening: (Date last done and result)

Housing

Indoor

Outdoor

Both

Current Symptoms

Diet

Treats

Yes

Any Allergies/Sensitivities?

Yes

Current Medications (Date started/List)

Current Medications (name/date started)

Current Supplements (Date started/Name)

Miscellaneous

Exercise

Who watches your pet when you go out of town?

In home pet sitter

Family/Friends

Boarding Facility

Any Fears/Anxieties?

Transport Behavior

Does your pet have a bite history?

Yes

Has your pet ever been given any supplements or prescribed any medications to manage his/her fear or anxiety associated with the visit? If so, what was it and what sort of results did you experience?

Does your pet have any special needs or requirements?

Yes

Age Related Cognitive Assessment Questions (check all that apply)

Disorientation

Stares intently where there is nothing visible

Does not remember his/her way back home

Gets stuck behind objects or furniture

Stays on the wrong side of the door

Does not respond to certain stimuli to which he/she used to respond to (i.e.. Doorbell)

Does not give any signal when he/she wants to go out

Sleep/Wake Cycles

Wakes during the night (without an obvious reason) when he/she did not use to do this

Vocalizes (barks, whines) during the night (without an obvious reason) when he/she did not use to do this

Social Interactions

Does not recognize familiar people

Does not recognize familiar animals

Shows more signs of fear or aggression towards people and/or other dogs than it used to

Learning and Memory

Urinates and/or defecates in new (inappropriate) places (when he/she did not used to)

Finds it difficult to respond to previously learned commands

Activity Level

Is less active or playful than he/she used to be

Shows repetitive behaviors (chases own tail, snaps at ‘invisible’ flies etc.)

Walks without obvious purpose

Anxiety

Shows more signs of anxiety when separated from his/her owners than before (main signs of anxiety are shaking, shivering or trembling, excessive salivation, restlessness/agitation/pacing, whining, loss of appetite)

IMPORTANT NOTICE

Fasting your pet at least 4 hours prior to the appointment in the event bloodwork is required, as well as bringing their most recent fecal sample and not allowing them to urinate upon arrival in case we need that sample will be most helpful.

PAYMENT POLICY

We will provide you with an estimate of fees for your pet’s medical care. You will have the opportunity to approve or decline all recommended procedures or medications. Your estimate will be adjusted to reflect only the services that you wish to pursue. Upon approval of the estimate, you will be invoiced for the items approved. THE BALANCE IS DUE AT DISCHARGE. HOSPITALIZATION/ANESTHESIA PROCEDURES If your pet is admitted to hospital due to an illness or if scheduled for a sedation or an anesthesia procedure, you will be required to pay a deposit which will be the total amount of the low-end of the estimate provided for the procedure. If you cannot meet this requirement, our front desk team can assist you in applying for Care Credit.

CONSENT, ACKNOWLEDGEMENT AND WAIVER

I hereby certify that, to the best of my knowledge, the information provided about my pet is true and accurate. I also understand that payment for services received is due at the time of my pet’s discharge. Depending on the nature of the service and/or time it takes to complete my pet’s treatment I understand that I may be required to drop off my pet and that partial payment may be requested at the time of drop off.

Authorized Signature

By selecting this box, I verify that I am the legal authorized agent for above named pets. And by this action I am signing this document.