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

  • Are you a new client?*

  • Other Authorized Person(s) on Account:

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  • Pet's gender*
  • Is your pet spayed/neutered?*
  • 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?*
  • 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.*
  • Appointment Date*
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    2 digit month, 2 digit day, 4 digit year
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  • Has your pet been coughing?*
  • Has your pet been sneezing?*
  • Does your pet have nasal discharge?*
  • Has your pet been vomiting?*
  • Has your pet had diarrhea?*
  • Does your pet's stool look normal color?*
  • Has your pet been drinking more?*
  • Has your pet been urinating more?*
  • Have you seen your pet's urine?*
  • Has your pet's appetite changed?*
  • Any change in diet?*
  • Is your pet lethargic?*
  • Is your pet here because it is limping? If so, which leg and how long?*
  • Has your pet cried out?*
  • Does your pet have problems with one or both of their eyes?*
  • Does your pet have problems with one or both of its ears?*
  • Do you have concerns with your pet’s teeth?*
  • Are there any new lumps or bumps you have found?*
  • 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.*

  • 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.

  • 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: