Exam Visit - Check In in Minneapolis, MN

• • • CLIENT INFORMATION • • •

Please fill out this form for existing appointments only. (*required)

Your Name*

Your Pet's Name*

Have you or anyone in your family/household shown signs of Covid, or had exposure to a person that has tested positive for Covid?*

Yes
No

Phone number to be used at this appointment*

Car make and model*

• • • VISIT INFORMATION • • •

Is it OK for us to give your pet clinic treats? (please bring your own for us to use if not)

Yes
No

If yes, is it also ok to give your pet peanut butter?

Yes, peanut butter is ok to give my pet.
No.

Your Pet's Diet

Your Pet's Current Medications and Supplements

Is your pet currently receiving parasite protection?

Yes
No

If yes, please tell us brand and type of parasite prevention.

DOGS ONLY: Are you interested in an injectable heartworm prevention product that lasts 12 months?

Yes
No

What preventative refills/doses would you like today?

What is the reason for your visit today?

Wellness/vaccines
Medical Concern

Medical Concern description

How is your pet's appetite?

Normal
Increased
Decreased

How is your pet's water consumption?

Normal
Increased
Decreased

Have you noticed any diarrhea, constipation, or other changes in stool?

Yes
No

Have you noticed any vomiting?

Yes
No

Have you noticed any coughing/sneezing/discharge/other respiratory signs?

Yes
No

Respiratory signs description

Have you noticed any limping/pain/stiffness, or other mobility issues?

Yes
No

Mobility Description

Have you noticed any skin or ear issues, such as itching/head-shaking/chewing/scooting?

Yes
No

Skin/Ear Description

Have you noticed any new lumps, or changes in existing lumps?

Yes
No

Lumps description

Do you have any other questions or concerns you would like to discuss at today's visit?

For the curbside appointment, I understand that:

Masks are required for any interaction with our team members
Pets must be on leash with secure collar or in a carrier
I must call the clinic upon arrival (612) 522-4374, option 2

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