Curbside Check In – Dallas Veterinary Clinic

I am in this vehicle: *

(please list model & color)

Best Phone number for today's appointment: *

(the Veterinarian and technician will use this number to communicate with you through the appointment.)

Email *

Patient's Name *

Patient's Species *

Canine
Feline

Owner's Name *

First

Last

Appointment Date/Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Patient's Energy Level *

Normal
Increased
Decreased

What brand of heartworm prevention do you use? *

Do you need a refill on heartworm prevention? *

Yes
No

Have you missed or had any late heartworm prevention doses? *

Yes
No

Would you like pet to receive Proheart 6 injection (heartworm protection which lasts 6 months) when the next administering is due? *

Yes
No

If heartworm test is due soon (we can take care of it today to save another trip), do you want us to send full internal organ health screening ($149)? *

Yes
No
Heartworm test is not due soon

What brand of flea/tick prevention do you use? *

Do you need a refill on flea/tick prevention? *

Yes
No

If any vaccines (except boosters that need to be spaced 3-4 wks apart) are coming up due in next 30 days, do you want us to go ahead and update those today if the doctor thinks it's okay to do so? *

Yes
No
No vaccines coming up

List Medications your pet is currently taking

Do you need refills of any of these medications

Yes
No

If you need a medication refill, please list which medications

Do you need refills on any prescription pet food? *

Yes
No

If you need a prescription pet food refill, please let us know which kind

Patient's Appetite *

Normal
Increased
Decreased

How long have you noticed this change? *

What type/brand of food are you feeding your pet? *

Drinking/Water Intake *

Normal
Increased
Decreased

Is the patient coughing? *

Yes
No

If yes, for how long? *

When did you first notice the problem? *

Please elaborate *

Is the patient sneezing? *

Yes
No

If yes, for how long? *

When did you first notice the problem? *

Please elaborate *

Is the patient vomiting? *

Yes
No

If yes, for how long? *

When did you first notice the problem? *

Please elaborate *

Has the patient had diarrhea? *

Yes
No

If yes, for how long? *

When did you first notice the problem? *

Please elaborate *

Is the patient licking/chewing/itching? *

Yes
No

If yes, for how long? *

If yes, how often? *

Please elaborate *

Do you want us to trim your pet's nails today? *

Yes
No

Any other services you'd like your pet to receive?

Any other concerns/questions/relevant observations?

Please upload any relevant photos / videos / records here

Click or drag files to this area to upload. You can upload up to 5 files.

I understand that DVC requires payment at the time services are rendered and does not offer payment plans or deferred billing of any kind. I take full responsibility for the pet(s) I'm presenting to DVC (either in person or virtually via phone/video consult) and agree to be fully financially responsible for paying in full TODAY. I understand and fully acknowledge that if I have a specific budget or any financial concerns or limitations I can ask for a treatment plan which will be provided before any treatments are performed, except for the office visit/exam/consultation, which I agreed to pay in full by coming here (or calling) and presenting my pet(s) or discussing my pet(s) with the veterinarian today. I understand that I can decline some services/goods, (even if against the advice of the veterinarian), if I am unable to pay for everything recommended and I promise to clearly decline items (EXCEPT the office visit/consultation/exam-which cannot be declined) if financially necessary BEFORE they are performed.

If you have budget constraints, kindly let us know before we see your pet.

Do you need a treatment plan with cost estimate before we treat your pet today? *

Yes
No

Signature *

Address

Hours

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