First Appointment Questionnaire

First Appointment Questionnaire

Please take a moment to complete this brief questionnaire prior to your appointment.

First Appointment Questionnaire
Name
Name
First
Last
Address
Address
Street
Apt / Suite
City
State
Zip
Preferred method of contact
How did you hear about us?
Would you like to add a secondary contact to the account?

Secondary Contact Information

Name
Name
First
Last

Pet Information

Maximum file size: 52.43MB

Species
Sex
Is your pet spayed or neutered?
(If unknown, approximate age)
Do you have previous medical records for your pet?

Maximum file size: 52.43MB

Has your pet seen a veterinarian before?
Does your pet have any allergies?
Is your pet currently taking any medications or supplements?
Does your pet have a microchip?
Are you interested in a microchip for your pet today?
Do you have pet insurance?
Why do we ask? We submit your claims for you after each visit!
Is your dog vaccinated for Canine Flu H3N8/H3N2?
Would you like more information on the Canine Bivalent Flu vaccine?
Canine Influenza H3N8 & H3N2 are contagious respiratory diseases caused by the influenza virus. It is spread by direct contact through the air during coughing, sneezing or contaminated objects. Recent outbreaks have become more common in the United States among unvaccinated dogs. Clinical signs may include fever, nasal discharge, lethargy, coughing and decreased appetite.
Do you travel often outside of the city with your pet in the northeastern United States?
Is your pet vaccinated against Lyme disease?
Would you like more information on Lyme disease and prevention?
Lyme disease is caused by a spirochete called Borrelia burgdorferi. A spirochete is a type of bacterium. It is transmitted to dogs through the bite of a tick. Once in the bloodstream, the Lyme disease organism is carried to many parts of the body and is likely to localize in joints. It was first thought that only a few types of ticks could transmit this disease, but now it appears that several common species may be involved. The most common type of tick to carry Lyme disease is the Deer Tick. A vaccine is now available for protecting dogs against Lyme disease. This vaccine is initially given twice, at two-week intervals. Annual revaccination is also necessary to maintain immunity. The vaccine has been shown to be safe and very effective.
Would you like to discuss the Lyme vaccine with your doctor?
Does your pet drink from standing water or frequent areas where there are rats, mice, squirrels, or raccoons?
Is your pet vaccinated against Leptospirosis?
Would you like more information on Leptospirosis and prevention?
Leptospirosis is a bacterial disease of dogs and other mammals that particularly affects the liver or kidneys. Leptospira bacteria are carried mainly by rats and other rodents, but can also affect almost any mammalian species, including people. Infected or recovered “carrier” dogs can also act as a source of the infection. Ingestion of infected urine or rodent-contaminated garbage is the most common means of transmission, but some forms of the bacteria can penetrate damaged or thin skin. For instance, when dogs swim in contaminated water, they may become infected through their skin. The incubation period (from infection to onset of clinical signs) is usually 4-12 days.
Would you like to discuss the Lepto vaccine with your doctor?
Do you give a monthly heartworm preventative?
Would you like more information on Heartworm disease?
Heartworm disease is a serious disease that results in severe lung disease, heart failure, organ damage, and possibly death in dogs, cats, and ferrets. It is caused by a parasitic worm called Dirofilaria immitis. The worms are spread through the bite of a mosquito. The dog is the definitive host, meaning that the worms mature into adults, mate, and produce offspring while living inside a dog. The worms are called “heartworms” because the adults live in the heart, lungs, and associated blood vessels of an infected animal. We recommend year-round heartworm prevention options which include monthly oral medications or long-acting injectable medication.
Are you interested in an injectable preventative called ProHeart that can protect your pet from Heartworm for 12 months?
ProHeart is an injectable parasiticide that is used in dogs 12 months of age and older to prevent heartworm disease. It offers a year of protection with one dose administered annually. It is a safe and effective alternative to monthly oral medications.
Does your cat go outside?
Do other animals live in the household?

Appointment Information

Masks are optional for clients and staff.

Hospital-Wide Hygiene Briefings

As an AAHA accredited hospital, Heart of Chelsea already subscribes to best practice veterinary maintenance and safety protocols. To further diminish COVID-19 risks, all hospital staff have received updated briefings on operational safety recommendations from the CDC. Our team members have all been instructed to stay home and seek appropriate care if they are sick.

Advanced Air Filtration

With the ability to reduce 99% of all microbes in a sneeze before they travel 3 feet, we hope to offer a little more peace of mind with our Advanced Air Filtration System and our existing protocols as we begin to allow clients back into our hospitals.

Watch this video for more information on Advanced Air Filtration technology.

Authorizations

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment.
I certify that I am the legal owner/agent of the above-mentioned pet(s) and I am hereby assuming all financial responsibility for treatment given to this animal by Heart of Chelsea Veterinary Group
I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, insurance company, urgent care facility, etc.), should they be requested.
Do you consent to sharing photos of you and/or your pet on social media?
By selecting this option, I hereby grant Heart of Chelsea Veterinary Group permission to take photographs of myself and/or my pet and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print. I also grant permission to use my pet’s name. Heart of Chelsea Veterinary Group will remove any published photo(s) previously consented to at the owner’s request. I authorize Heart of Chelsea Veterinary Group to edit and share the aforementioned photograph(s). I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above.

Signature