Appointment History Information Form

We look forward to seeing you soon! Please complete the form below as accurately and completely as possible. If you have any questions, you can contact us at 419-517-5042.

Today's Date *

Client Name *

First

Last

Phone *

Email *

Pet's Name *

Reason for Appointment

Please list current Medications

Which heartworm and/or flea/tick preventives is your pet on currently?

Any Medication Refills needed today?

Any Preventives (such as Interceptor or Simparica) needed today?

Your Pet’s current diet:

Please list the treats that you give to your pet:

Has your pet’s appetite been normal? *

Please elaborate:

Any vomiting or diarrhea at home recently? *

Please elaborate:

Any coughing, sneezing, congestion at home recently? *

Please elaborate:

Any other concerns today?

Is this an illness appointment? *

Please describe your pet's illness and the duration of it

Is the illness improving, remaining the same, or worsening since first noticed? *

Please list any treatments you've tried at home and if there has been any change from the treatment:

Client Signature *

Clear Signature

Message

7851 W Sylvania Ave.
Sylvania, OH 43560

Mon – Fri: 8:00am – 6:00pm
Sat: 8:00am – 1:00pm

Please Note: We are closed from 1pm to 2pm, Monday through Friday.

Phone: 419-517-5042
Email: info@timberstonevet.com
Fax: 419-517-5044