Pre-Exam Questionnaire

When You Arrive

Park at BHPH Only please.

Once you arrive please remain in your car. Send a text message to 203-324-5711 with the following information:

IN ONE SINGLE SENTENCE Please send the following:

Your name and your pet’s name
For Doctor’s Exam: Name of Doctor you are scheduled to see (Dr. Steven Zeide, Dr. Nolan Zeide, or Dr. Nick Milano)
Color/make/model of your car

*If no one comes to pick up your pet within 5 minutes, please text again or call 203-324-5711 and press #

Pre-Exam Questionnaire

We kindly request that you complete this required form, and return it to us 72 hours prior to your pet’s appointment, so that the doctor has time to review it, in advance of your visit.

Your Information

Owner's Name

Best Phone Number to Reach You

Appointment Information

Date and time of appointment

Pet Information

Pet Name

Have you or your pet been in contact with anyone who has tested positive, is testing for COVID-19, or is presumed to have had COVID-19? *

Yes

If yes, please explain, as we will need to take appropriate precautions.

Are there any recent or historical medical issues you are concerned about?

Yes

If yes, please explain the medical issues.

Anything else we should know that has not been covered in the above questions?

Yes

If yes, please explain what hasn't been covered.

Do you need any flea/tick or heartworm preventatives while you are visiting with us today?

Yes

If yes, how many of each?

Bravecto

Interceptor

Credelio

Parastar

Revolution

Signature *

I accept

By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement and the Disclaimer. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

Type Your Name to E-Sign: *

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