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Wellness Questionaire - Powell Animal Hospital - Powell, TN

Powell Animal Hospital

205 Star Mountain Way (Formerly500 W Emory Rd)
Powell, TN 37849

(865)938-1884

powellanimalhospital.com

Wellness Questionaire Form

Owner's Name (required)
First Name (required)
Last Name (required)
Phone number where you can be reached: (required)
Phone TypePhone Number (required)
Emergency Contact Number:
Phone TypePhone Number
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Pet's Name (required)

Ideally what would be the best timefor you to pick-up your pet today? (required)

Does your pet spend most of the time indoors, outdoors, or both equally? (required)

indoors only
outdoors only
sometimes indoors, sometimes outdoors
both equally


Is your pet every boarded or groomed? (required)

yes
no


How often?

weekly
monthly
quarterly
annually


Is your pet exposed to other animals, including dog parks and neighborhood walks? (required)

yes
no


Does your pet travel out of state or go camping with you? (required)

yes
no


If your pet DOES travel or camp with you, to what parts of the country do you go and how often?

Is your pet exposed to any wildlife, including raccoons, opossums, rats, skunks, squirrel and deer?

yes
no


Is your pet ever exposed to water, including streams, lakes, rivers, or standing water in yards?

yes
no


In the past month has your pet had any vomiting or diarrhea? Which one and how often?

In the last month, has your pet had any coughing or sneezing?

Any changes in eating habits in the past 3 months?

What type of food and treats does you pet eat and how much?

Any changes in water consumption or urination in the last month?

yes
no


If you answered "yes", what changes have occurred?

Any changes in behavior the past three months?

Is there anything specific that you would like addressed with your pet?

Does your pet receive flea, tick, and/or Heartworm medication each month?

Yes
No


Does your pet take any other medications on a regular basis?

Would you like to be called and given an estimate for today's services?

Yes
No


What is (are) the best phone number(s) to reach you today?

Powell Animal Hospital Drop-off Policy:
Please note that we require all pets staying with us for the day to be current on vaccinations and to have had a negative fecal examination within the past 6 months. If your pet is due vaccinations, your pet will be vaccinated before treatments are performed. Additionally, your pet must be free from both external and internal parasites. If treatment for parasites is necessary, this will be performed at your expense.
Authorization:
By submitting this form, I authorize the doctors at Powell Animal Hospital to perform the diagnostics and treatments that they feel necessary up to the amount I listed above. I understand that if additional services are necessary, I will be contacted by a doctor so that we can discuss these procedures and their cost. If I cannot be reached, I give my permission for the doctors to perform any necessary emergency treatments that may be needed to stabilize a life-threatening condition. I agree to assume all financial responsibility for these treatments in the case of an emergency.
I have read the above statement, and I - (required)

agree
disagree



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