ANIMAL HOSPITAL OF MONTICELLO
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Pre-Visit Questionnaire
Please complete form prior to appointment
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Indicates required field
Scheduled appt date and time
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Name
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First
Last
Please confirm Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell Phone Number
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Email
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Patient Name
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Species
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Canine
Feline
Sex
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Neutered Male
Spayed Female
Male
Female
What is the primary reason for this appointment? (Please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility)
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If you are bringing a dog are they on heartworm and flea/tick prevention:
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Yes
No
If you clicked yes, please list:
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List all other medications and supplements your pet is currently taking, including any that manage his/her fear or anxiety for vet visits. (medication/supplement name, dose, frequency)
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Do you need any refills of any medications/supplements today?
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How is your pet's appetite?
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Normal
Increased
Decreased
Comments:
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How is your pet's thirst level?
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Normal
Increased
Decreased
Comments:
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Has your pet had any nausea, vomiting, or regurgitation?
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Yes
No
Comments:
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How are your pet's bowel movements?
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Normal
Abnormal
Comments:
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How is your pet's urination?
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Normal
Abnormal
Comments:
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How is your pet's energy/activity level?
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Normal
Abnormal
Comments:
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Is this pet indoor or outdoor?
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Indoor only
Outdoor only
Indoor, but outdoor to eliminate
Diet: Please describe everything your pet eats as thoroughly as possible including food brand, amounts, treats, and special things like table food
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Any additional information you would like to discuss during your pet's visit today?
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Any additional information you would like our team to know about your pet?
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Do we have permission to share your pet's photo on our website, social media, and marketing channels?
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I agree (YES)
I disagree (NO)
*By agreeing, you agree to our photo-release terms of service.
--I hereby grant Animal Hospital of Monticello permission to use my pet's likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of Animal Hospital of Monticello and will not be returned. I hereby irrevocably authorize Animal Hospital of Monticello to edit, alter, copy, exhibit, publish or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my pet's likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge Animal Hospital of Monticello from all claims, demands, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Appointment procedures
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I understand that payment is due in full at the time services are rendered. For your convenience we accept all major credit cards, Care Credit, and cash. Hospitalization and major procedures may require a deposit. Any delinquent balances receive an interest rate accessed at 2% per month.
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Home
Services
Meet our Team
Tour
Client Center
New Client Form
Pre-Visit Questionnaire
Sign up for our app
Appointment Request
Adoption Application
CareCredit
Emergency
