Client Form – Mulitple Pet’s | Sequist Animal Hospital

Updates on COVID-19 - Hospital Policies For All Appointments

*This form is required for all appointments with a doctor. Please fill this form out at your earliest convenience and at least 24 hours before your appointment.

*If you or a member of your household have traveled out of state (or entered into VT) within the last 14 days and/or are ill with COVID-19 or ANY OTHER respiratory illnesses you will need to reschedule for when your quarantine is over and/or you are feeling better. Please contact us in order to reschedule if need be.*

I understand the above statement

* When interacting with staff employees it is required that you wear a mask properly covering your mouth and nose. We also request that you stay at a 6 foot distance when possible.*

I understand the above statement

* Upon arriving to your appointment you MUST CALL to let us know that you are here. If you are unable to reach a person please CALL BACK every 5 minutes until you are able to reach a person. We appreciate your patience at this time. We are doing our best to be as efficient as possible but our phones lines can sometimes all be in use.*

I understand the above statement

* Once you connect with a person to state that you are here we will collect your payment method (we are ONLY accepting debit/credit cards - NO checks or cash) and have the technician get on the phone to discuss in detail your concerns/questions and what you would like done during the appointment. The technician will then meet you at the front entrance door to get your pet, bring them in the building (while you remain in the car), and the technician and doctor will proceed accordingly with the agreed upon treatment and/or diagnostics.*

I understand the above statement

*We do request that when you are here for your appointment that you STAY. If you leave the property there will be a boarding fee.*

I understand the above statement

Client Information

Owner's Name (First, Last)*

Owner's Home Phone*

If you do not have one please put NA

Owner's Cell Phone*

If you do not have one please put NA

Owner's Email*

This is where your invoice will be sent after your visit.

Significant Other's Name (First, Last)

Only if applicable

Significant Other's Cell Phone

Only if applicable

Significant Other's Email

Only if applicable

Current Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How do you prefer to get your appointment reminders?*

Please select all that apply.

Select All
Phone
Email
Text

What places is it ok for us to release your pet's medical records to?*

Please check all that apply.

Other Vets
Daycares
Boarders
Groomers
Rescue Shelters
Town Offices
Insurance Companies
None

Please list anyone else (not listed above) you would like to give permission to bring your pet/s in. Be sure to include anyone who may watch your pet/s while you are away.

Have you or anyone in your household traveled out of the state in the last 14 days?*

Yes
No

Are you, or anyone that lives with your pet, exhibiting symptoms of COVID-19 (cough, shortness of breath, fever) or has tested positive for COVID-19?*

Yes
No

Who will be present for the appointment?*

If we have additional questions, what phone number should we call when you are here for your appointment?*

What vehicle will you be arriving in? (color/make/model)*

At the end of your visit would you like the technician to give you a quote/total of your bill?*

All appointments, whether you want a total or not, will receive an itemized invoice via email.

Yes
No

Would you like an assessment of your pet's health after the visit?*

Yes - Verbally
Yes - Written
No

Can we take a picture of your pet/s?*

This would be added to their account and potentially used on social media.

Yes
No

Patient Information (1st Pet)

Name*

Breed*

Age or DOB*

Color*

Sex*

Male
Female

Does your pet have a microchip?*

Yes
No
Unknown

Does your pet have health insurance?*

Yes
No
Unknown

Patient Medical Background

If your pet is having diarrhea please bring a fresh fecal sample (no older than 24hrs and needs to be refrigerated if you are not coming right in with it).

If your pet is having urine issues please bring a fresh urine sample (no older than 24hrs old and needs to be refrigerated if you are not coming right in with it).

If your pet has been vomiting please collect a sample of vomitus for review by the doctor.

Have you noticed any of the following?*

What symptoms have you noticed?

Select All
Coughing
Sneezing
Nasal Discharge

What symptoms have you noticed?

Select All
Weight Change
Appetite Change

What symptoms have you noticed?

Select All
Vomiting
Diarrhea

What symptoms have you noticed?

Select All
Skin Irritation
Ear Irritation

Has the change been....

Select All
Sudden
Gradual

Please describe what is going on with your pet and the symptoms you are noticing.

Do you know how this happened? If yes, please explain.

Please describe what you are visually noticing and the location of the injury.

Briefly describe the symptoms.

Have the symptoms worsened recently? Is your pet uncomfortable? Is there oozing, itching, and/or a smell?

Have you changed your pet's diet or exercise? If yes, please explain.

When did symptoms start?

Have you treated the symptoms at all prior to the appointment? If yes, please explain with what and for how long.

Where are the lumps/bumps located?

When did you first notice the lumps/bumps?

Have symptoms....

Worsened
Remained the same
Gotten slightly better

Is your pet actively bleeding?

Yes
No

Briefly describe the symptoms.

Is your pet in noticeable discomfort? How frequently is your pet urinating inappropriately? Does the urine appear to be discolored or have an odor?

Briefly describe the lumps.

Are they hard or soft? Approximately how big are they?

Does your pet have any diarrhea or are they vomiting?

Yes
No
Unsure

Are they painful to touch?

Yes
No
Unsure

Is there a chance that your pet got into something? If yes, please explain.

Are symptoms worse at a certain time of day or before/after activity or rest? If yes, please explain

Has your pet had a fecal test recently?

Yes
No
Unsure

Do they board or are they around other animals with or without a cough?

Yes
No

Appetite is....

Normal
Minimal
No appetite

Did you change your pet's diet prior to symptoms?

Yes
No

Water consumption is....

Normal consumption
Minimal consumption
Excess consumption
Unsure

Has your pet's energy levels changed? If yes, please briefly explain.

Are there any other symptoms you would like us to be aware of?

Patient Information (2nd Pet)

Name*

Breed*

Age or DOB*

Color*

Sex*

Male
Female

Does your pet have a microchip?*

Yes
No
Unkown

Does your pet have health insurance?*

Yes
No
Unkown

Patient Medical Background

If your pet is having diarrhea please bring a fresh feal sample (no older than 24hrs and needs to be refrigerated if you are not coming right in with it).

If your pet is having urine issues please bring a fresh urine sample (no older than 24hrs old and needs to be refrigerated if you are not coming right in with it).

If your pet has been vomiting please collect a sample of vomitus for review by the doctor.

Have you noticed the following*

What symptoms have you noticed

Select All
Coughing
Sneezing
Nasal Discharge

What symptoms have you noticed?

Select All
Weight Change
Appetite Change

What symptoms have you noticed?

Select All
Vomiting
Diarrhea

What symptoms have you noticed?

Select All
Skin Irritation
Ear Irritation

Has the change been....

Sudden
Gradual

Please describe what is going on with your pet and the symptoms you are noticing.

Do you know how this happened? If yes, please explain.

Please describe what you are visually noticing and the location of the injury.

Briefly describe the symptoms

Have the symptoms worsened recently? Is your pet uncomfortable? Is there oozing, itching, and/or a smell?

Have you changed your pet's diet or exercise? If yes, please explain.

When did the symptoms start?

Have you treated the symptoms at all prior to the appointment? If yes, please explain with what and for how long?

Where are the lumps/bumps located?

When did you first notice the lumps and bumps?

Have symptoms....

Worsened
Remainded the same
Gotten slightly better

Is your pet actively bleeding?

Yes
No

Briefly describe the symptoms.

Is your pet in noticeable discomfort? How frequently is your pet urinating inappropriately? Does the urine appear to be discolored or have an odor?

Briefly describe the lumps.

Are they hard or soft? Approximately how big are they?

Does your pet have any diarrhea or are they vomiting?

Yes
No
Unsure

Are they painful to the touch?

Yes
No
Unsure

Is there a chance that your pet got into something? If yes, please explain.

Are the symptoms worst at a certain time of day or before/after activity or rest? If yes, please explain.

Has your pet had a fecal test done recently?

Yes
No
Unsure

Do they board or are they around other animals with or without a cough?

Yes
No

Appetite is....

Normal
Minimal
No Appetite

Did you change your pet's diet prior to symptoms?

Yes
No

Water consumption is....

Normal consumption
Minimal consumption
Excess consumption
Unsure

Has your pet's energy levels changed? If yes, please briefly explain.

Are there any other symptoms you would like us to be aware of?

Additional Pet Health Questions

Is it ok for both of your pet's to have treats and/or peanut butter during their appointments?*

Yes
No

Do either of your pet's have allergies? If yes please explain. If no please put NA.*

Would you like your pet's to have nail trims while they are here?*

Additional charges may apply.

Yes
No

Please list any medications, supplements, or preventatives your pets are taking currently and who is getting what.

Do you need any medication, supplemens, and/or preventatives?*

Yes
No

Please list what medications, supplements, and/or preventatives you would like and the quantity.*

Is it a challenge to medicate your pet?*

Yes
No
Unsure

What type of food do you currently feed your pets?*

How much do you feed your pet and how often during the day?*

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

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Client Form – Mulitple Pet’s

Client Form - Multiple Pet's

Updates on COVID-19 - Hospital Policies For All Appointments

Client Information

Patient Information (1st Pet)

Patient Medical Background

Patient Information (2nd Pet)

Patient Medical Background

Additional Pet Health Questions

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