ARLINGTON CAT CLINIC – Pre-Exam Questionnaire

1
What day and time is your appointment?* This field is required.
Date
Year
Month
Day
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
2
Owner First Name
Owner Last Name
Cell Phone
Patient Name
Email Address
Services Requested Today (please list)
Indoor
Outdoor Supervised
Outdoor Unsupervised
Indoor/ Outdoor Supervised/ Outdoor Unsupervised
3
Owner Date of Birth* This field is required.We occasionally prescribe controlled substances and must have a humans date of birth on file for our feline patients.
Date
Month
Day
Year
4
Pet's Diet Please make sure to complete this section before moving forward with the form.
Number of cats in household
Other pets
Diet: Brand dry
Amount/day
Brand canned
Amount/day
Table scraps
Treats
5
Yes
No
Is your cat currently taking any medications, flea preventive, heartworm preventive or food supplements?
Type
Dose
Type
Dose
6
Any changes in your cat’s attitude or activity level?* This field is required.
Yes
No
7
Any changes in how much your cat eats or drinks?* This field is required.
Yes
No
8
Any problems with coughing, sneezing, or breathing?* This field is required.
Yes
No
9
Any problems with the eyes, ears or nose?* This field is required.
Yes
No
10
Any hair loss, sores, lumps, scratching or other skin problems?* This field is required.
Yes
No
11
Any problems with vomiting?* This field is required.
Yes
No
12
If yes, please specify
Huge
Large
Normal
Small
Ok
Ok
13
Any problems with diarrhea?* This field is required.
Yes
No
14
If yes, please specify
Huge
Large
Normal
Small
Ok
Ok
15
Any problems with hard or dry stools?* This field is required.
Yes
No
16
Does your cat ever urinate or defecate outside the litter box?* This field is required.
Yes
No
17
Does your cat have a hard time jumping or climbing stairs?* This field is required.
Yes
No
18
Any changes in the amount of urine or stool?* This field is required.
Yes
No
19
Yes
No
Do you have pet insurance?
Insurance Company
Do you have any questions or concerns today that are not covered above?
20
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED

In admitting/presenting my pet(s) for diagnostics, treatment, surgery, I authorize the doctors of Arlington Cat Clinic, LTD and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for hospitalization and surgeries. No guarantee or assurance can be made as to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment if possible. I agree to pay the Arlington Cat Clinic, LTD at the time services are rendered. If the account goes delinquent; no payment in 30 days, the account will be assessed a 2.00% billing fee on the outstanding balance(24% yearly). I further agree if the account is transferred to collections, I will be responsible for all costs necessary to collect this balance including collection fees, attorney fees, court costs, and filing fees. If a check is returned non-sufficient funds, a minimum charge of $25.00 will be added to the amount owed.
21
Signature* This field is required.Please Type your Full Name
Should be Empty: