Date Form Completed *

The Cell Phone Number of the person coming to the appointment with your pet *

Name of Patient *

Reason For Today's Visit *

What diet is your pet currently on? Brand names, frequency, people food, etc. *

Pet Lifestyle - Select the following that applies to your pet *

Go outside

Go to the park or go hiking

Go to daycare/ boarding / grooming facility

During the last month, have any of the following problems occurred?

General

Weight Loss

Weight Gain

Vomiting

Diarrhea

Change in appetite

Coughing and/or sneezing

Increased thirst or urination

Have you noticed any of the following in your pet?

Skin

Lumps, bumps, sores or swelling on their skin? *

Yes

No

If yes, are there any changes in growth, and hardness or discomfort for your pet?

Yes

No

What is the duration of time since you've noticed this?

Excessive scratching, licking of paws or irritation? *

Yes

No

If yes, what is the duration of time since you've noticed this?

Ears

Ear problems? (Scratching, shaking head, discharge, foul smell) *

Yes

No

If yes, is it their right ear, left ear, or both?

Right

Left

What is the duration of time since you've noticed this?

Eyes

Vision Changes? *

Yes

No

Irritation, redness or discharge? *

Yes

No

If yes to either, what is the duration of time since you've noticed this?

Dental

Bad breath, trouble chewing, tartar? *

Yes

No

If yes, what is the duration of time since you've noticed this?

Mobility

Lameness, stiffness, difficulty on stairs or walking? *

Yes

No

Any other evidence of arthritis? *

Yes

No

If yes to either, what is the duration of time since you've noticed this?

Please use to following section to provide us information about medications your pet is currently taking. Include:

The Name of the Medication

The Medication's Strength (Example: 50mg, 100mg, etc)

How You Give It To Your Pet (How much/many? How often?)

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Will you require any medication refills while you are here? *

Yes

No

If yes, what is the name of the medication?

Does your pet take any preventatives (flea and tick heartworm, etc)? *

Yes

No

If yes, what is the name of the preventative?

If your pet take preventatives, do they do so every month?

Yes

No

Are you interested in signing up for our wellness plan?* *

Yes

No

*Stoney Creek is proud to offer our clients (and patients) a “Health Care Wellness Plan” to aid in the yearly preventative medicine that is recommended (by our Veterinarians) for pets. This is not an insurance or sick pet plan. This plan only covers core wellness and preventative medicine recommended to you by your veterinarian, for the year. That means that we have met with your veterinarian and made a list of essential vaccines, bloodwork, preventatives as well as your pet’s health exam and a second 6 month wellness exam that your pet will need for the year. We then discounted the total of all of these exams and services by 10%. The plan allows you to make monthly payments (on this total) over the course of 12 months instead of you paying the total all at once at your pet’s annual visit. When you sign up for the Wellness Plan you will also receive a 10% discount on some of our most common services. (SQ Fluids, Anal Gland Expression, Ear Clean — Basic or Extensive, Hot Spot Treatment, In House Cytology — Ear/ Lump/ Skin, Laser Treatment, Microchip, Nail Trim, Wound Cleaning)

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