GVH Diagnostic Exam Questionnaire

Please fill out a questionnaire for each pet coming in for a sick visit with the doctor.

IMPORTANT UPDATE REGARDING HOSPITAL PROCEDURES

As of 1/20/21 we will be offering CURBSIDE ONLY services for all examinations and visits. A veterinary nurse will come to your vehicle when you arrive to bring your pet inside and you will be able to communicate with the doctor by phone. 

Thank you for your patience and cooperation.

 

General Information

Primary Owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If this is a cell number, we can send you text reminders for appointments.

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This is where you'd like to receive health service reminders and detailed appointment reminders, in addition to the text reminders. You can opt out of one or the other at any time.

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If your pet received a rabies vaccine or any other vaccines from another veterinarian, please provide us with their contact information and we'll gladly call to obtain those records for you. Please be aware that if the rabies vaccine is expired, records cannot be obtained by us or you aren't able to bring them in, we will be required by law to administer this vaccine at the time of the visit, if your pet is healthy enough to receive it.

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Please list all medications and suppliments your pet takes on a regular basis, how much and how often.

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Please give any details you feel are relevant to your pet's present condition.

Is your pet eating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet drinking normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet urinating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet defecating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has there been a recent change in your pet's diet? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please indicate the dollar amount not to exceed.

If your pet is due to be updated on vaccines, would you like that done, providing your pet is healthy enough to receive them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Will you need us to fill out a pet insurance claim form or provide you with records from your visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you do not yet have pet insurance but would like more information, please go to our website! We give you the names of a few companies some of the staff and our clients use. You'll also find links with coverage questions and a comparison chart to help you make the best decision for your family. Please let us know if you have any questions!

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GVH Diagnostic Exam Questionnaire

GVH Diagnostic Exam Questionnaire

Please fill out a questionnaire for each pet coming in for a sick visit with the doctor.

IMPORTANT UPDATE REGARDING HOSPITAL PROCEDURES

As of 1/20/21 we will be offering CURBSIDE ONLY services for all examinations and visits. A veterinary nurse will come to your vehicle when you arrive to bring your pet inside and you will be able to communicate with the doctor by phone. 

Thank you for your patience and cooperation.

 

General Information

Primary Owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Appointment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Primary Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Previous vaccine and medical records {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet currently taking any medication, including heartworm, flea or tick prevention? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What are the main concerns for the doctor to address today? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet eating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If not, please explain. (If you have not already explained above.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet drinking normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If not, please explain. (If you have not already explained above.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet urinating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If not, please explain. (If you have not already explained above.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is your pet defecating normally? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If not, please explain. (If you have not already explained above.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What kind of food does your pet eat? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has there been a recent change in your pet's diet? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any kinds of diagnostic testing you would like to pre-approve the doctor to perform, IF NEEDED?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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You can also pre-approve the doctor to perform any diagnostic testing she deems neccessary up to a dollar amount of your choosing. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If your pet is due to be updated on vaccines, would you like that done, providing your pet is healthy enough to receive them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Will you need us to fill out a pet insurance claim form or provide you with records from your visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you do not yet have pet insurance but would like more information, please go to our website! We give you the names of a few companies some of the staff and our clients use. You'll also find links with coverage questions and a comparison chart to help you make the best decision for your family. Please let us know if you have any questions!

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