Curbside History Form – Hartford Animal Clinic

Curbside Care Form
COVID-19 SAFETY UPDATE

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Curbside Care: Medical History Form

During the COVID-19 Pandemic, our practice is moving to “curbside care” to limit physical contact and adhere to social distancing recommendations. These new procedures help to limit exposure, not only to pet owners, but also to our veterinary team.

Please call the office once you have arrived and parked. You must have your pet on a leash or secured in a carrier before we meet at the front door.

In order for your veterinary healthcare team to provide comprehensive care for your pet, please fill in this form prior to your visit.

Date:*
dd/mm/yyyy
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?*
- Yes
- No
Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?*
- Yes
- No
Owner's Name
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Pet Information
Pet's Name*
Species*
if other please specify
Breed (if known)
Sex
Color
Date of Birth or Age (if known)
Pet Health - Reason for Visit
Describe your concern*
How long has this been going on?*
Days/Weeks/Months
What are you currently feeding the pet?*
food/treats
How is their appetitie?*
poor/good/excellent
Are you currently giving any medications or supplements?*
- yes
- no
Please specify*
name/dose/last given
Any coughing, sneezing, nasal discharge, or other respiratory signs?*
- yes
- no
Please describe*
Any vomiting or diarrhea?*
- yes
- no
Please describe*
Any limping, pain, stiffness or other mobility issues?*
- Yes
- No
Please describe*
Any skin issues?*
- Yes
- No
Please describe*
Have they gotten into anything? Eaten anything unusual?*
- yes
- no
Please describe*
Is your pet indoors only? (Cats)
Any environmental changes?*
Describe their behavior*
lethargic/normal/hyperactive
Any changes to thirst?*
increased/normal/decreased
Any changes to urination?*
increased/normal/decreased
How are their bowel movements?*
normal/abnormal
If your pet has any masses that concern you, please describe:*
Please use this comment section to include any questions or concerns you have.*
Important Information! Please Read Below:
Please call the office once you have arrived and parked. You must have your pet on a leash or secured in a carrier before we meet at the front door.
- Please be sure to take your pet out of your vehicle - for health and safety reasons, our staff cannot climb into your vehicle to gather up your pet. We can meet you at the double doors and take your pet into the clinic.
- We ask that you do not leave while we are taking care of your pet (unless a drop-off was arranged due to special testing, etc), as the Veterinarian will call you during the exam or after to discuss findings and treatment/next steps. We do not have the staffing or facilities to keep your pet beyond the completion of their appointment.
- It is extremely important that you provide a number to reach you, as was mentioned above, the Veterinarian may need to speak with you and we will need to call you for payment when your pet's visit is complete.
We appreciate your understanding and cooperation during this unique situation and thank you for trusting us with your pets.
I authorize curbside service and care of my pet by the veterinarians and staff of Hartford Animal 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.
Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY

Contact

1191 Grand Avenue
Hartford, WI 53027

Phone: (262) 673-7960
Fax: (262) 673-5804
Email: [email protected]

Clinic Hours

Monday: 7:30am – 7:30pm
Tuesday: 7:30am – 7:30pm
Wednesday: 7:30am – 7:30pm
Thursday: 7:30am – 7:30pm
Fri: 7:30am – 6:00pm
Sat: 7:30am – 12:00pm
Sun: Closed

Emergencies

Wisconsin Veterinary Referral Center
Waukesha Location: (866) 542-3241
Grafton Location: (262) 546-0249
www.wvrc.com

Lakeshore Animal Hospital
Port Washington: (262) 268-7800
Glendale: (414)-540-6710
www.lakeshoreanimalhospital.com

Animal Poison Control
Veterinary toxicologists available 24 hours a day
888-426-4435

Home
New Clients
About Us
Services
Pet Health
My Pet
Contact Us

Curbside Care Form
COVID-19 SAFETY UPDATE

Curbside Care: Medical History Form

Due to the COVID-19 prevalence, we want to ensure your safety, and that of our team. Please answer yes/no to these questions:

Owner's Name

Pet Information

Pet Health - Reason for Visit

Important Information! Please Read Below:

Contact

Clinic Hours

Emergencies