First Time Consultation Forms

So that we may better serve you, please complete this online form about you and your pet.  The second half is a questionnaire to help us better understand your pet’s lifestyle and any changes you may have noticed. Completing these forms online will allow for faster check-in upon arrival for your appointment.  Simply fill out the form below and click submit once you have answered all of the questions.  If you are unable to complete the online form, you may download the form here to complete and bring with you to your appointment.

Owner:

CO-OWNER/SPOUSE:

Pet Information:

May we use information pertaining to your pet and your pet’s case, including a photo of your pet, in our marketing efforts; including but not limited to our website, continuing education, charitable events, etc.?
yesno

PRIMARY CARE VETERINARIAN:

I understand that payment in full is due at the time of service. I agree to assume financial responsibility for all professional fees, and agree to pay VVSA when services are rendered. I understand that a fee of $50.00 will be incurred for all returned checks and a finance charge of 1.5% per month will be applied to any unpaid balance. VVSA may also recover reasonable attorney’s fees and court costs incurred as a result of my failure to pay in accordance with this authorization.


yes
Please type your FULL name in the box provided below.
This will act as your electronic signature and authorization of the above
statement:

YOUR PET’S MEDICAL HISTORY:

What is the primary reason you are seeing a veterinary surgeon?
Describe your pet’s general activity level:
increaseddecreasedremained normal

When your pet is outside,
is she/he confined to a
fenced yard or leashed?
yesno

Describe your pet’s water intake:
absentdecreasedincreasednormal
Describe your pet’s appetite:
absentdecreasedincreasednormal

What type of food do you feed your pet?
Commercial foodPrescription dietTable scrapsOther

When did your pet last eat?
Have you observed
any lameness,
limping, or difficulty
walking?
yesno

Which limb(s)
are affected?
Right foreLeft foreRight rearLeft rear

Have you noticed any
unusual coughing?
yesno

Have you noticed any
unusual sneezing?
yesno

Have you noticed any
discharge from the ears,
eyes, nose, mouth,
rectum, or genitals?
yesno

Has there been any
consistent vomiting?
yesno

Has there been any
consistent diarrhea?
yesno

Has there been a consistent
change in your pet’s bowel
movement frequency or
stool consistency?
yesno

Have you observed
any changes in
your pet’s urination
behavior or frequency?
yesno

Has your pet ever
had a seizure?
yesno

Does your pet take any
medication(s) to prevent
seizures?
yesno

Has your pet traveled out of
the Mid-Atlantic States?
yesno

Are your pet’s
vaccinations current
within the last
12 months?
yesno

Please describe all medication (including heartworm prevention and
flea control) your pet is currently taking.
Has your pet ever experienced an adverse or allergic reaction to any medication?
yesno

Number of other pets that share the household:
Are any of these
pets current or
past patients of
Virginia Veterinary
Surgical Associates?
yesno