We welcome you to accompany your pet inside the hospital for your visit. Please note that face masks are required for anyone entering the clinic. If you prefer a curbside appointment, please call us at (607) 273-3133 and notify us of your arrival.

Patient's Name *

Patient's Species *

Canine
Feline

Owner's Name *

First

Last

Preferred Pronouns

Email *

Phone *

This will be the primary number we will use to communicate with you regarding your pet's care.

Your Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Appointment Date/Time *

Date

Time

As Fear Free Certified Professionals, we want to make your pet’s veterinary experience as enjoyable and as stress-free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your and your pet’s preferences.

Does your pet show any reluctance to getting in the carrier?

Yes
No

How and where does your pet travel in the car (e.g., carrier, seatbelt, loose, etc.)?

During travel to the veterinary clinic, does your pet do any of the following:

Please specify:

Primary reason for appointment *

Wellness
Sick/concern
Recheck

What concern do you have? (please be as detailed as possible) *

Patient's Energy Level *

Normal
Increased
Decreased

When did this start? *

Patient's Appetite *

Normal
Increased
Decreased

When did this start? *

Drinking / Water Intake *

Normal
Increased
Decreased

When did this start? *

Is the patient: *

When did the coughing start? *

How frequently is the coughing occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet coughing per hour? *

Once
Twice
Three times
More

How many times is your pet coughing per day? *

Once
Twice
Three times
More

How many times is your pet coughing per week? *

Once
Twice
Three times
More

How many times is your pet coughing per month? *

Once
Twice
Three times
More

Would you describe the coughing as… *

Dry and non-productive (no discharge)
Wet and productive (possible discharge)
Other

If other, please describe *

Any known trauma your pet may have experienced? *

Yes
No

If yes, please describe *

Does your pet spend time around other pets? I.e. dog park, daycare, boarding, etc. *

Yes
No

When did the sneezing start? *

How frequently is the sneezing occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet sneezing per hour? *

Once
Twice
Three times
More

How many times is your pet sneezing per day? *

Once
Twice
Three times
More

How many times is your pet sneezing per week? *

Once
Twice
Three times
More

How many times is your pet sneezing per month? *

Once
Twice
Three times
More

Is there any discharge produced when your pet sneezes? *

Yes
No

What color discharge are you seeing? *

Does your pet spend time around other pets? I.e. dog park, daycare, boarding, etc. *

Yes
No

When did the vomiting start? *

How frequently is the vomiting occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet vomiting per hour? *

Once
Twice
Three times
More

How many times is your pet vomiting per day? *

Once
Twice
Three times
More

How many times is your pet vomiting per week? *

Once
Twice
Three times
More

How many times is your pet vomiting per month? *

Once
Twice
Three times
More

When was the last time your pet vomited? *

Does your pet vomit after any particular activity? *

How soon after the activity? *

Immediately
Hours after

If other, please describe *

Is the vomit... *

Bile
Food
Mix of both
Other

If other, please describe *

Are you aware of anything inside or outside of the house your pet may have gotten into? *

Yes
No

If yes, please explain *

When did the diarrhea start? *

How frequently is the diarrhea occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet having diarrhea per hour? *

Once
Twice
Three times
More

How many times is your pet having diarrhea per day? *

Once
Twice
Three times
More

How many times is your pet having diarrhea per week? *

Once
Twice
Three times
More

How many times is your pet having diarrhea per month? *

Once
Twice
Three times
More

When was the last time your pet had diarrhea? *

Would you describe the diarrhea as… *

Liquid (water)
Soft with no form (pudding consistency)
Soft with some form (soft serve ice cream)
Other

Is this occurring EVERY time your pet passes stool? *

Yes
No

If other, please describe *

Are you seeing any… *

Is the blood... *

Bright red
Dark red

Have you made any changes to your pet’s diet? *

Yes
No

What changes and when? *

Are you aware of anything inside or outside of the house your pet may have gotten into? *

Yes
No

If yes, please explain *

Has the concern... *

Improved and is completely resolved
Improved, but is still present
Not changed since last visit (neither improved nor worsened)
Worsened

What is it you are seeing at home? *

What brand of pet food does your pet eat? *

How much are you feeding for each meal? *

Measured amount
Guesstimated amount
Free fed

Quantity given *

How often are you feeding the above amount? *

Please describe *

Are you giving anything else at home that would contribute to your pet’s diet? *

Yes
No

Please specify *

List ALL medications or supplements your pet is currently taking. Please ensure to provide product name, concentration, and the amount and frequency of which you are giving the medication. *

Do you need a refill of any of these medications? *

Yes
No

Please specify *

What brand of flea/tick preventative are you using? When was the last dose given? *

What brand of heartworm preventative are you using? When was the last dose given? *

Would you like your pet’s nails trimmed today? *

Yes
No

Please note there is an added fee for this service.

Does your cat ever urinate outside of the litter box? *

Yes
No

When did this start? *

How frequently is it occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet inappropriately urinating per hour? *

Once
Twice
Three times
More

How many times is your pet inappropriately urinating per day? *

Once
Twice
Three times
More

How many times is your pet inappropriately urinating per week? *

Once
Twice
Three times
More

How many times is your pet inappropriately urinating per month? *

Once
Twice
Three times
More

Do you notice any of the following? *

Does your cat ever defecate outside of the litter box? *

Yes
No

When did this start? *

How frequently is it occurring? *

Hourly
Daily
Weekly
Monthly

How many times is your pet inappropriately defecating per hour? *

Once
Twice
Three times
More

How many times is your pet inappropriately defecating per day? *

Once
Twice
Three times
More

How many times is your pet inappropriately defecating per week? *

Once
Twice
Three times
More

How many times is your pet inappropriately defecating per month? *

Once
Twice
Three times
More

Is the stool normal in appearance? *

Yes
No, abnormal

Please describe

How many litter boxes do you have in your household? *

Are your litter boxes… *

Covered
Uncovered
Mix of both

How often do you clean the litter boxes? *

If other, please specify

Have you changed anything about the litter box? *

Litter
Placement/location
Type of box
No change

Old litter brand *

New litter brand *

Does your cat spend any time outdoors? *

No, indoor ONLY
Yes, but supervised time ONLY (i.e. leash/harness, patio with you outside, catio, etc.)
Yes, and unsupervised time

What are your pet's favorite treats? (You are welcome to bring some for your pet's visit!)

Does your pet like to play with toys? If so, what kinds?

Do you have any additional questions or concerns about your pet that you would like to discuss at this visit? Please specify:

File Upload

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

Please use this field to attach any relevant documents for your pet's medical records that we do not already have. This includes medical records from a different veterinarian, vaccination certificates, etc.

Please remember we request 24 hours advanced notice of the need to cancel or change an appointment. Failure to notify our office of the need to cancel an appointment may result in a fee being charged to your account. *

I acknowledge and understand the statement above.

Appointment Preparation Form

Get In Touch

We've proudly served the pets of Ithaca, NY for over 30 years.

Contact Info

Address

Hours

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