Pre-Exam Questionnaire

Pre-Exam (Doctor’s Appointment) Questionnaire >

Pre-Short Visit or Nurse Visit Questionnaire >

When You Arrive

NOTE: PLEASE PARK IN FRONT OF BHPH OR DOWN THE LONG DRIVEWAY AT DUNKIN’. NO PARKING ALLOWED AT JOHN THE BAKER.

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 + pet’s name
Where you’re parked? Our lot or Dunkin’ lot
Car Color/Make

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

Pre-Exam (Doctor’s Appointment) Questionnaire

Is your appointment a Short Visit or Nurse Visit? Please use the form below.

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, and which doctor are you seeing?

Pet Information

Pet Name

Has your pet been in contact with anyone who has tested positive or presumed to have had COVID-19? If so, we will need to take appropriate precautions

Yes or no, please describe

What is your pets current diet including quantity and frequency fed? Include pet food, human food, treats, chews.

Any change in appetite, water consumption, or urinations? If so, please explain.

Any change in energy level? If so, please explain.

Any recent vomiting or diarrhea? If so, please explain.

Any excessive coughing or sneezing? If so, please explain.

Any licking/scratching/itching? If so, where? Please rate level of itching/scratching from 1 (very comfortable) - 10 (extremely itchy)

Any lumps/bumps you are concerned about? If so, where? When did you first notice?

Is your pet on any medications? Include prescriptions, supplements, and flea/tick + heartworm preventatives (Bravecto, Interceptor?) long with dosage amount and frequency.

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

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

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Pre-Short Visit or Nurse Visit 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.