Roscommon Curbside Appointments (MVP)

Curbside History Form

Please have this form complete before coming to the hospital. Your pet will be brought into the hospital by a team member. The doctor will do an exam and any questions/conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment for services will be curbside as well and expected after the visit is complete.
Due to the COVID-19 prevalence, we want to ensure your safety and that of our team. Please answer yes/no to these questions:
*Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.
Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough or difficulty breathing?*

YesNo
Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?*

YesNo
Your Name*

First NameLast Name
Pet's Name*
Please provide a phone number that the doctor can call you on to discuss the exam.*

Area CodePhone Number
IMPORTANT NOTE:
Please be sure that the phone number you provided above is correct.

This is the phone number that the doctor will call during the exam to discuss your pet's health. It is IMPORTANT that you have this phone on hand during the time of the exam.
Purpose of visit:*
Are you a new client?*

YesNo
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Other Authorized Person(s) on Account:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
How did you hear about?
Pet Type*
(ex. dog, cat, bird...)
Breed (if applicable)
Color(s)/Marking(s)
Estimate age or date of birth*
Pet's gender*

MaleFemale
Is your pet spayed/neutered?*

YesNo
How long have you owned your pet?
When was the last time your pet received a vaccine?
Last veterinarian who provided services for your pet
If there any previous medical problems or allergies of which we should be aware, please list and describe them here:
If your pet is currently on any medications, please list what type(s), and frequency here (including heartworm & flea medication):
What brand of pet food do you currently feed?
Photo Consent: We love to take photos of our patients for educational purposes, marketing, social media, our website and medical charting reasons. No personal information will be used without your permission. Do you consent to allowing us to take and/or use photos of your pet for the above described purposes?*

YesNo
Due to the nature of the services rendered in this office, full payment is required when services are rendered. Please indicate below your choice of payment.*

CashPersonal CheckVisa/Mastercard/DiscoverCare CreditScratchpay
Appointment Date*

MonthDayYear
Date
Appointment Time*

:HourMinutesAM/PM Option
Has your pet been coughing?*

YesNo
Has your pet been sneezing?*

YesNo
Does your pet have nasal discharge?*

YesNo
If so, what color and which nostril(s)?
Has your pet been vomiting?*

YesNo
If your pet has been vomiting, when what the last time and describe the vomit.
Has your pet had diarrhea?*

YesNo
Does your pet's stool look normal color?*

YesNo
If no, is it black or bloody? Describe.
Has your pet been drinking more?*

YesNo
Has your pet been urinating more?*

YesNo
Have you seen your pet's urine?*

YesNo
If so, what's the color and the amount?
Has your pet's appetite changed?*

YesNo
If so, describe how.
When was the last time you saw a bowel movement and what did it look like?
Any change in diet?*

YesNo
If yes, when and what did you change in their diet?
Is your pet lethargic?*

YesNo
If yes, how long have they been lethargic?
Is your pet here because it is limping? If so, which leg and how long?*

YesNo
If yes, how long has your pet been limping, and which leg for how long?
Please list all medications your pet is on and when they were last given.*
Has your pet cried out?*

YesNo
If yes, what was your pet doing when this occurred?
Does your pet have problems with one or both of their eyes?*

YesNo
If yes, which eye? Describe any drainage or symptoms.
Does your pet have problems with one or both of its ears?*

YesNo
If yes, which ear? Describe any discharge or symptoms.
Do you have concerns with your pet’s teeth?*

YesNo
If yes, please describe.
If there are any concerns with your pets anal glands, such as any scooting or licking, please describe.
Are there any new lumps or bumps you have found?*

YesNo
If yes, where are they and how long have they been present?
We are now offering Proheart 12. If you are having a heartworm test done today, please check here if you would be interested in a 12 month injection for heartworm prevention. A technician will be happy to answer any questions you may have.*

YesNo
Please use this comment section to include any questions or concerns you have. Please also include any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.
Curbside appointments must arrive 10 minutes prior to appointment. If you are scheduled for a routine, annual exam, we recommend yearly blood work and viral screening, fecals checked twice yearly, and vaccines due updated. We will provide an estimate of what we have in our records that are needed for your pet for your review when we come to your car.

Please have your pet on the leash or in a carrier before we come to the car.
When you park, please call the office to let us know once you have arrived. To help us assist, please let us know the color, make, and model of your car.
(White Jeep Wrangler)
I authorize curbside service and care of my pet by the veterinarians and staff of Roscommon Veterinary Clinic. I understand this may involve my pet being accompanied by a staff member during their visit,rather than myself. I understand that staff members will be handling my pet;they may be approaching and/or partially entering my vehicle or meeting me at the clinic door. Further medical authorization of recommended treatment(s) will be done via phone communication; I consent to over the phone financial and treatment authorization.
Should be Empty:

Curbside History Form