Pre-Exam Questionnaire

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Pre-Exam Questionnaire

WHEN YOU ARRIVE

Bull’s Head Pet Hospital has returned to in-person care on February 21, 2022.

Upon arrival, please coming into reception to be helped.

If you are human, leave this field blank.

Your Information

Owner’s Name

Best Phone Number to Reach You

Email

Appointment Information

Date and time of appointment

Pet Information

Pet Name

For Doctor exams ONLY, please choose one of the following options:

Inside hospital

Zoom from car

(All non-Doctor exams and services remain fully curbside ONLY, at this time).

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

Yes

No

If yes, please explain the medical issues.

Is your pet on any medications? Include prescriptions, supplements, and flea/tick + heartworm preventatives (Bravecto, Interceptor?)

Yes

No

If yes, please list them all, along with their dosage, amount, and frequency.

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

Yes

No

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

No

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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