Recheck Exam Admission Form

Have you or anyone in your household traveled outside of Canada in the last 14 days?*

Yes
No

Are you currently exhibiting any of the following symptoms?*

Yes
No

Fever, cough, shortness of breath, difficulty breathing, sore throat or painful swallowing, runny nose or stuffy nose, feeling unwell/fatigued, conjunctivitis, etc.

Have you or anyone in your household had close contact with someone who is being investigated or confirmed to be a positive case of COVID-19?*

Yes
No

Are you bringing in an animal that has been in contact with a person that has or is COVID-19 positive in the past 14 days?*

Yes
No

We kindly ask that you DO NOT leave the parking lot unless otherwise instructed during your appointment time. We also ask that you keep your phone on you at all times in order for us to efficiently contact you regarding your pet.*

I CONSENT

*Some pets exhibit fearfulness/anxiety/stress during their visit with us and we aim to reduce the amount that they experience. In doing so, we may send your pet back with you in the car after we have examined them due to this.

Name*

Age*

Please specify weeks/months/years*

Weeks
Months
Years

Sex*

Neutered Male
Male
Spayed Female
Female

My Pet Was Initially Seen For*

Please List Medications and Doses of Medications That Your Pet Has Been on*

If your pet was prescribed any pre-visit medications (Gabapentin/Trazodone/Phenobarbital, etc), please list them and what time they were given (if none were given, put N/A):*

Do You Feel That the Condition Has Improved?*

Yes
No

If no to the above question, please describe in detail why the condition has not improved:

My Pet Is Eating and Drinking Normally*

Yes
No

My Pet Has Normal Energy Levels*

Yes
No

Are there additional concerns that you want addressed today?*

Do you have pet insurance, if so, what company & list the policy number:

Best phone number to contact you during the time of appointment*

Contact Us

Hours of Operation

Scratchpay

Emergencies

Healthsmart

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