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Dear Valued Clients, During the COVID-19 Pandemic, many

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© LIFE LEARN INC. All rights reserved. www.lifelearn.com
Dear Valued Clients,
During the COVID-19 Pandemic, many veterinary clinics are moving to
“curbside care” to limit physical contact and adhere to social distancing
recommendations. These new procedures help to limit exposure, not only to
pet owners, but also to our veterinary team.
In order for your veterinary healthcare team to provide comprehensive care
for your pet, please:
1. Fill in this form
2. Return via email prior to your visit
When you arrive for your appointment, please call our office from your vehicle.
A member of our team will you meet you there to start the appointment.
Thank you for your patience and participation in keeping our families safe.
This form is only accessible on a desktop computer. If you attempt to open it on
your mobile phone, its features may not function properly.
© LIFE LEARN INC. All rights reserved. www.lifelearn.com
Medical History Form Date:
CLIENT INFORMATION:
Client Name:
Address:
Phone: Home Cell Work:
Email:
PATIENT INFORMATION:
Pet Name:
Species: Dog Cat Other
Sex: M F
Spayed/Neutered: YES NO
Breed:
Color:
Date of Birth:
PATIENT HISTORY:
Describe your concern:
© LIFE LEARN INC. All rights reserved. www.lifelearn.com
How long has it been going on? DAYS WEEKS MONTHS
What are you currently feeding your pet?
How is their appetite? POOR GOOD EXCELLENT
When did they eat last?
Are you currently giving any medications or supplements? If so: NAME/DOSE/LAST GIVEN
Any coughing or sneezing? If so, please describe:
Any vomiting or diarrhea? If so, please describe:
Have they gotten into anything? Eaten anything unusual?
Is your pet indoors only? (CATS) YES NO
Any environmental changes?
How is their behavior? LETHARGIC NORMAL HYPERACTIVE
Any changes to thirst? INCREASED NORMAL DECREASED
Any changes to urination? INCREASED NORMAL DECREASED
How are their bowel movements? NORMAL ABNORMAL
When was their last bowel movement?
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Dear Valued Clients, During the COVID-19 Pandemic, many

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Completed 23 February 2021

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