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Curbside History Form

Please have this form complete before coming to the hospital. your pet will be brought into the hospital by a team member, the doctor will do an exam and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment of services will be over the phone if credit card, and expected after the visit is complete. we will notify you if you are to wait, or if we will have you leave your pet and we will call you to let you know when their discharge time is.

Due to the COVID-19 prevalence, we want to ensure your safety and that of our team. Please answer yes/no to these questions:

*Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.

Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough or difficulty breathing?*

Yes

Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?*

Yes

If the answer is yes to either of the above questions, we may need to reschedule your appointment. Please call us at 231-947-2365! We are using AIRVET (a telemedicine app) to help see pets, this may be an option for you. If we feel the pet NEEDS to be seen, we will let you know and will ask for an unaffected person to bring them if possible.

First Name*

Last Name*

Pet's Name*

Phone*

Email*

Appointment Date*

MM slash DD slash YYYY

Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer ALL QUESTIONS below regardless of why your pet is here.*

Has your pet been coughing?*

Yes

Has your pet been sneezing?*

Yes

Does your pet have any nasal discharge? If yes, please describe the color and which nostril(s)

Has your pet been vomiting? If yes, when was the last time and describe the vomit.

Has your pet had diarrhea?*

Yes

If your pet's stool does not look normal, is it black or bloody? When was the last time you saw a bowel movement?

Has your pet been drinking more?*

Yes

Has your pet been urinating more? If so, what was the color and amount?

What do you feed your pet?

If your pet's appetite has changed, please describe how so

If your pet's diet has recently changed, please share when and what did you change in their diet?

If your pet is lethargic, how long have they been lethargic for?

If your pet is limping, how long has your pet been limping, and which leg for how long?

Please list all medications your pet is on and when they were last given*

If your pet has cried out, please share what your pet was doing

If your pet has problems with one or both of their eyes, please describe any drainage, symptoms, and which eye

If your pet has problems with one or both of their ears, describe any discharge, symptoms, and which ear

If you have any concerns with your pet's teeth, please describe

Would you like your pet's nails trimmed while here?*

Yes

If there are any concerns with the nails, please describe

Would you like your pet's anal glands emptied?*

Yes

Are there any concerns about your pet's anal glands? Any scooting or licking, please describe.

Are there any new lumps or bumps you have found? If so, please describe where, and when it was noticed?

Please use this comment section to include any questions or concerns you have. Please also include any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.

For wellness exams, we recommend annual bloodwork. We will call you with the bloodwork choices and cost if you would like to proceed. Blood work is discounted if you need a heartworm test or fecal at the same time.

Would you like bloodwork today for your pet?*

Yes

If you need any medications or food refills, please list what and how many

If your pet has a current heartworm test, are you requesting HEARTGARD PLUS today? We do have rebates again this year! If so, how many?

All dogs need flea/tick prevention. We carry two options: NEXGARD (chewable) and FRONTLINE GOLD (topical). Do you need some? If so, which kind and how many?

All cats need parasite prevention, we have REVOLUTION PLUS (topical all in one) or HEARTGARD (oral) and FRONTLINE GOLD (topical) as a combination product. Do you need some? If so, which one and how many?

Please go ahead with diagnostics and treatments if the costs are not over $350. We will call you if we are expecting costs to go over $350, or if you have checked no.*

Yes

Curbside appointments must arrive 10 minutes prior to appointment. If you are scheduled for a routine annual exam, we recommend yearly blood work and viral screening, fecals checked twice yearly, and vaccines due updated. We will provide an estimate of what we have in our records that are needed for your pet for your review.

Please have your pet on a leash or in a carrier before we come to the car. You will be given a slip leash to put on your dog. Please get out of your car to hand the leash to our team member.

Please text our office (231)409-7566 when you arrive with your name, space, and purpose. If you cannot text, call our office once you have arrived (231) 947-2365

Note: Our cell phone is only for texting your arrival. Please do not call the cell number or ask questions via text, as they will not be answered.

Please bring a fecal and urine sample, so if needed, it is available.

I authorize curbside service and care of my pet by the veterinarians and the team of Long Lake Animal Hospital. I understand my pet will be accompanied by a team member during their visit, rather than myself. Further medical authorization of recommended treatment(s) will be done via phone communication; I consent to over the phone financial and treatment authorization.

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Curbside History Form

Curbside History Form

What's Next

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