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Phone: (970) 484-1848 | Fax: (970) 484-1251 | Mon, Tue, Thu, Fri: 7AM - 6PM | Wed: 7AM - 7PM | Sat, Sun: Closed

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Exam Questionnaire

Today's Date(Required)

Month

Day

Year

Date of Appointment(Required)

Month

Day

Year

Owner's Name(Required)

First Last

Owner's Email(Required)

Pet's Name(Required)

Pet Health - Reason for Visit

Please list what you are bringing your pet in for including any specific questions or concerns(Required)

What is the current diet being fed?(Required)

How much is your pet being fed?(Required)

Is the above diet grain free?(Required)

Yes

No

Are you currently giving any medications, vitamins or supplements?(Required)

Yes

No

Please provide more details

Any coughing or sneezing?(Required)

Yes

No

Please provide more details

Any vomiting or diarrhea?(Required)

Yes

No

Please provide more details

Has your pet been excessively itching or scratching?(Required)

Yes

No

Please provide more details

Have you noticed any new lumps or bumps on your pet? Or existing lumps that have grown or are bothering your pet?(Required)

Yes

No

Please provide more details

Has your pet’s activity level been normal? Are they getting around well?(Required)

Yes

No

Please provide more details

Has your pet been eating and drinking normally?(Required)

Yes

No

Please provide more details

Are you giving your pet Heartworm and or flea prevention?(Required)

Yes

No

Please provide more details

Do you have any behavioral concerns?(Required)

Yes

No

Please provide more details

Is your pet mostly indoors or outdoors(Required)

Indoors

Outdoors

Has your pet traveled out of the local area?(Required)

Yes

No

Please provide details

Are you able to brush your pet’s teeth at home or give dental treats?(Required)

Yes

No

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CONTACT INFO

1015 S. Taft Hill Rd, Ste T
Fort Collins, CO 80521

Phone: (970) 484-1848
Fax: (970) 484-1251

HOSPITAL HOURS

Mon, Tue, Thu, Fri: 7:00 AM - 6:00 PM

Wed: 7:00 AM - 7:00 PM

Sat, Sun: Closed

Please see our Holiday Schedule

Patients seen by appointment.

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