847-673-2520
[email protected]
5335 Touhy Ave Skokie, Illinois, 60077
About Us
Our Doctors
Our Core Values
Take A Tour
Services
Anesthesia and Patient Monitoring
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination
Laser Therapy
New Clients
What to Expect
Links
Pet Health
How-To Videos
Pet Health Checker
Pet Health Library
News
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Online Store
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Medical Questionnaire
Please fill out the required sections of this form for your upcoming visit. We are excited to see you and our four-legged friend. Please note this form is not intended for scheduling of appointments.
Name
*
First
Last
Pet Name
*
Email
*
Cell Phone Number
*
Reason for the Visit
*
Appointment Date
*
Date Format: MM slash DD slash YYYY
Doctor
Dr. Baksys
Dr. Manthei
Dr. Peterson
Dr. Sachen
Dr. Sutkay
Dr. Wardisiani
Tech Visit
Please let us know which doctor your pet will be seeing. If unsure please leave blank.
Health Screen
*
Healthy with no health concerns
Vomiting
Diarrhea
Coughing
Sneezing
Change in appetite
Change in urination
Change in bowel movement
Mobility Issues
Skin Issues
Seizure Activity
Yes
No
Seizure Activity
Please provide more information in regards to the seizure activity... (Last seizure, frequency, duration, etc)
Adverse reactions to medications or vaccinations
Yes
No
Adverse Reactions
Please provide information in regards to the history of adverse reactions...
Additional information or concerns
Please provide more information for any health issues checked off above: such as duration, frequency, and severity of the concern.
Lifestyle
*
Please tell us about your pet's lifestyle.
Strictly Indoors
Indoor/Outdoor
Boarding
Daycare
Grooming
Frequents wooded areas
Dog Parks/ Beaches
Travels out of state/ the country
Are there other pets in the household?
*
Yes
No
Diet: (Brand, type, amount, and frequency)
*
Is your pet currently taking medications?
*
Yes
No
List current medications
Do you need a refill of medication?
Yes
No
Medication(s) to refill:
Parasite Preventatives
*
Parasite preventatives are recommended year-round. Please check off the preventative your pet is taking.
Heartgard
Nexgard
Frontline
Revolution
Other
Not currently on any preventatives
Other:
If you checked off other under the parasite preventative section please let us know what preventative medication your pet is receiving.
Does your pet need a refill of parasite preventatives?
Yes
No
Additional services needed today
Vaccines
Nail trim
Anal glands
Laser therapy
Other:
Other:
Additional Comments:
About Us
Our Doctors
Our Core Values
Take A Tour
Services
Anesthesia and Patient Monitoring
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination
Laser Therapy
New Clients
What to Expect
Links
Pet Health
How-To Videos
Pet Health Checker
Pet Health Library
News
Payment Options
Contact
Online Store