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 travelled outside of Canada in the last 14 days?

Yes
No

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

Yes
No

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?

Yes
No

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):

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:

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:

Are there other pets in the home?

Yes
No

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

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 *

Please note: We will be closed at noon on Thursday, June 30th and fully closed Friday, July 1st for Canada Day!

Patient History Form

Complete this form before your visit.

Appointment Procedures

We proudly care for the pets of Lethbridge, Alberta.

We’re here for you!

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