Patient History Form

Complete this form before your visit.

In order to help us provide your pet with the best possible care, please fill out this patient history form in its entirety. If you have any questions or concerns, please call us at 403-327-7387.

Pet's Name *

First

Last

Your Name *

First

Last

Email *

My pet has an appointment booked for: *

As of July 2nd, 2020, Highlands Pet Hospital is now allowing clients back into the building. Please make note of the following protocols if entering the building:

A mask must be worn at all times.
Only one family member per appointment.
Three clients allowed in reception at one time.
Please practice social distancing wherever possible.

Have you or your pet traveled outside of Canada in the last 14 days?

Have you, someone in your home, or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?

Have you or someone in your home been asked by a health care professional or Alberta Health Services to quarantine in the last 14 days?

Reason for your pet's visit today?

This issue began on:

This issue is:

Has your pet had any of the following symptoms (choose all that apply):

Coughing
Sneezing
Vomiting
Diarrhea
Weight loss
Seizures

Please tell us more:

Has your pet had any:

New lumps or bumps
Behaviour changes
Changes in mobility

My pet's appetite is:

My pet's thirst level is:

My pet's activity level is:

My pet's urination is:

My pet eats:

Wet food only
Dry food only
Wet and dry mixture
People food
Raw diet
Home cooked diet

Brand of pet food:

If prescription diet, what formulation?

How often is your pet fed?

How much is your pet fed per day?

In addition to pet food, what treats or other food does your pet receive? (Include any human food, dental products, bones, rawhides, etc.)

Has your pet's diet changed in the last 6 months?

Yes
No
I am not sure

Has your pet been dewormed in the last 12 months?

Yes
No
I am not sure

When was your pet's last dose of flea/tick prevention?

What kind of flea/tick prevention do you use for your pet?

Please list any medications, supplements, or topical treatments your pet has received in the past month that are not listed above, and tell us when they were last given.

Is your pet:

Indoor only
Mostly indoor but rarely to occasionally spends time outdoors
Indoor/outdoor
Outdoor only
Outdoor during the day/inside at night

Are there other pets in the home?

In regards to lifestyle, does your pet usually (select all that apply):

Visit the dog park
Attend doggie daycare
Board or kennel
Get groomed regularly
Attend obedience training
Attend agility, search and rescue programs, etc.
Compete in dog/cat shows
Travel with you outside of Alberta
Travel with you outside of Canada

Is your pet up to date on vaccines?

Yes
No
I am not sure

My pet's vaccines were last administered by:

Highlands Pet Hospital
I am not sure where
Other

My pet's vaccines were last administered by:

Does your pet have a microchip?

Yes
No
I am not sure

Has your pet bitten anyone in the last 15 days?

Yes
No
I am not sure

Does your pet have known health concerns and/or chronic disease or conditions?

Is there anything else we should know about your pet?

Are there any pictures or videos that would help us with our exam today?

Click or drag a file to this area to upload.

Is there anything else you would like to discuss today?

Appointment Procedures

I understand COVID-19 protocols must be followed if entering the building. This includes wearing a mask while in the building, using hand sanitizer upon entering, and social distancing whenever possible.

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone.

Signature *

Name

We proudly care for the pets of Lethbridge, Alberta.

Our mission is to provide compassionate, trusted, quality care to our patients and their families. If you have questions or need anything at all, our contact information is below. We look forward to seeing you soon!

We’re here for you!

Address

2550 Highlands Rd W
Lethbridge, Alberta T1J4V3

Contact Info

Phone: 403-327-7387
Email: info@highlandspethospital.ca

Hours

Mon – Fri: 8:00 am – 5:30 pm
Weekends: Closed

APPOINTMENT

Drop Us a Line

Don’t be shy. Let us know if you have any questions!

One of our team members will be in touch with you within 1 – 2 business days.

Name *

First

Last

Email *

Phone

How can we help you? *

Phone