pre-appointment form – Brockville Animal Hospital

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Date: _______________________________________________________________________________
(Date of Admittance)
Affix labels here:
(Office use only)
Date of Your Pet's Appointment*
Date Format: MM slash DD slash YYYY
OWNER'S INFORMATION:
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Enter Email Confirm Email
CO-OWNER'S NAME AND CONTACT INFO:
Name
First Last
Phone
PET INFORMATION:
Pet's Name*
Species*
Colour*
Is your pet spayed or neutered?*
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Coughing?*
- Yes
- No
If Yes, please provide details.
Sneezing?*
- Yes
- No
If Yes, please provide details.
Vomiting?*
- Yes
- No
If Yes, please provide details.
Diarrhea?*
- Yes
- No
If Yes, please provide details.
Seizures?*
- Yes
- No
If Yes, please provide details.
Weakness?*
- Yes
- No
If Yes, please provide details.
Excessive Drinking?*
- Yes
- No
If Yes, please provide details.
Loss of Appetite?*
- Yes
- No
If Yes, please provide details.
Any concerns with skin/lumps/bumps?*
- Yes
- No
If Yes, please provide details.
Any concerns with mobility?*
- Yes
- No
If Yes, please provide details.
Do you have any other concerns to go over at your pet's appointment?*
- Yes
- No
If Yes, please provide details.
What does your pet eat in a typical day? Please provide name of food/treats and amount of each.
Any changes in appetite?
Any changes in drinking?
Please list any medications or supplements your pet is taking and when they are given.
Does your pet have any known allergies to medications?*
- Yes
- No
If yes, please list.
Does your pet go outside, visit kennels, groomers or dog parks?*
- Yes
- No
If your pet requires any vaccinations would you like us to give them while here? (additional fees apply)*
- Yes
- No
We recommend bringing a stool sample with you to your pets appointment. Would you like a fecal test run for your pet to check for parasites? This is recommended annually by our veterinarians. (additional fees apply)*
- Yes
- No
Would you like your pet's nails trimmed during their appointment?*
- Yes
- No
If not already, would you like us to microchip your pet? (additional fees apply)*
- Yes
- No
Would you like your dog tested for Heartworm/Lyme Disease? (additional fees apply)*
- Yes, I would like my dog tested
- No, I would not like my dog tested
- I have a cat
Would you like your dog to have a Lyme vaccination? (additional fees apply)*
- Yes, I would like my dog to have a Lyme vaccination
- No, I would not like my dog to have a Lyme vaccination
- I have a cat
Would you like your dog to have a Kennel Cough vaccination? (optional but included in cost)*
- Yes, I would like my dog to have a Kennel Cough vaccination
- No, I would not like my dog to have a Kennel Cough vaccination
- I have a cat
Do you have pet insurance?*
- Yes
- No
If yes, what is the name of your pet insurance provider?
Have you downloaded our Brockvillevet App?*
- Yes
- No
If no, please download the Brockvillevet App and active your account to collect loyalty paw reward stamps for your pet's visit. We will add loyalty stamps to your app once payment is received. When you download the app be sure to create an account using the same email address we have on file for you. Please let us know if you have any questions.
Please let us know if you are having any issues downloading and setting up your app account. We are happy to help!
CONTACTING YOU DURING APPOINTMENT:
Will you be bringing your pet to their appointment?*
- Yes
- No
If no, please provide the name/relationship (example: my mom) of the person who will be bringing your pet to their appointment.
Does this person have permission to make health and/or financial decisions for you or your pet on your behalf?
- Yes
- No
If no, please indicate the best contact information where we can reach YOU during your pet's appointment:
Would you like us to text or email you?*
- Yes
- No
If yes, please confirm your cell phone number and e-mail address:
We like to take a photo of patients during their visit with us. Do we have your permission to post your pet's photo on our social media pages if we take a picture during their appointment?*
- Yes
- No
Received by: _______________________________________________________________________________
(Office use only)
Owner/Guardian Signature: _____________________________________________________________
(Owner signs here at pet's admittance)

Brockville Animal Hospital

681 Stewart Blvd.
Brockville, ON K6V 5T4

Phone: 613-345-3401
Email Us

Hours of Operation

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 4:00pm
Sunday	Closed

*We are closed Tuesdays between 1-2PM for staff training

Waterfront Veterinary Services

Limited hours of operation.
Please call for details.

26 Water Street, East
Brockville, ON K6V 1A1

Phone: 613-345-3401
Email Us

Emergency Info

For emergencies outside of regular office hours please call 613-345-3401 to reach our after hours emergency triage service.

For emergency care after 8:00 p.m. or Statutory Holidays please call:

Ottawa Animal Emergency & Specialty Hospital: 613-745-0123 or contact one of these emergency veterinary hospitals.

Emergency Hospital List

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About Us
Services
Pet Health
Contact Us
- Online Consult
Shop Online
Rewards