Owners First Name*

Owners Last Name*

Email*

Preferred Phone Number *

When is your pet's appointment?*

Pet's Name: *

Is Driftwood your regular veterinarian?*
—Please choose an option—YesNo, but I would like them to beNo

Is your pet currently having any problems?*
—Please choose an option—YesNoOther

On a scale of 0 to 10, how would you rate your pet's pain?*
—Please choose an option—1 No Pain2345678910 Worst Pain

How has your pet been eating?*
—Please choose an option—NormalIncreasedDecreased

What brand of food does your pet eat?*

How much does your pet eat?*

Has your pet been drinking water?*
—Please choose an option—NormalIncreasedDecreased

Has there been any vomiting or diarrhea?*
—Please choose an option—YesNo

How would you characterize your pet's urination?*
—Please choose an option—NormalIncreasedDecreasedPainfulStrainingNot Urinating

Is your pet on any medication?*
—Please choose an option—YesNo

Would you like to speak to the veterinarian today?*
—Please choose an option—Yes, please call me after the exam.Yes, please call me ONLY if there is something wrong with my pet.No, I do not need to talk to the vet today.

In the case you cannot be reached by phone, how would you like us to proceed in the case of a LIFE-THREATENING emergency situation?*
*Please note, the procedures done in this case may go over the budget listed above.
—Please choose an option—Please DO NOTHING until I am reached.Please PERFORM LIFE-SAVING procedures but nothing else until I am reached.Please USE PROFESSIONAL JUDGEMENT and proceed accordingly.

Due to budgetary constraints, please consult me before going over this price point?*
*Please note, the minimum charge for any patient starts with an exam fee.

By marking, "I Agree" to this question, I am authorizing Driftwood Vet to treat my pet according to how I filled out this questionnaire.*
I Agree