ARLINGTON CAT CLINIC – Pre-Exam Questionnaire

1
Today's Date* This field is required.
Date
Month
Day
Year
2
Owner Name
Patient Name
Primary Phone
Home
Cell
Work
Type
Email Address
Services Requested Today (please list)
Indoor
Outdoor
Both
Indoor/Outdoor
Free roam
Supervised
Not always supervised
Deck
Balcony
Please Specify
3
Number of cats in household
other pets
Diet: Brand dry
Amount/day
Brand canned
Amount/day
Table scraps
Treats
4
Yes
No
Is your cat currently taking any medications, flea preventive, heartworm preventive or food supplements?
Type
Dose
Type
Dose
5
Any changes in your cat’s attitude or activity level?* This field is required.
Yes
No
6
Any changes in how much your cat eats or drinks?* This field is required.
Yes
No
7
Any problems with coughing, sneezing, or breathing?* This field is required.
Yes
No
8
Any problems with the eyes, ears or nose?* This field is required.
Yes
No
9
Any hair loss, sores, lumps, scratching or other skin problems?* This field is required.
Yes
No
10
Any problems with vomiting or diarrhea?* This field is required.
Yes
No
11
Any problems with hard or dry stools?* This field is required.
Yes
No
12
Does your cat ever urinate or defecate outside the litter box?* This field is required.
Yes
No
13
Does your cat have a hard time jumping or climbing stairs?* This field is required.
Yes
No
14
Any changes in the amount of urine or stool?* This field is required.
Yes
No
15
Yes
No
Do you have pet insurance?
Insurance Company
Do you have any questions or concerns today that are not covered above?
16
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.
17
Signature* This field is required.
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