Online Form

Patient History and Evaluation Form

Complete your required forms online from any device at any time before your visit.

Patient History and Evaluation

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name(Required)

First Last

Phone(Required)

Email(Required)

Pet Information

Pet Name(Required)

Pet's Diet - please include any snacks, human food, and/or supplements(Required)

Inside or Outside Pet?(Required)

Inside

Outside

Both

Does pet contact other pets outside/ daycare/ groomer/ pet store/ parks/ traveling/ boarding etc?

Does pet swim or contact pond, lake, stream or puddle water or travel on pasture land?

Ticks or fleas noted?(Required)

Yes

Is your pet currently on any medications?(Required)

Yes

Medication

Dose

Frequency

Last given?

Need refill?

Yes

Is your pet currently on any supplements/nutraceuticals?

Yes

Medication

Dose

Frequency

Last given?

Need refill?

Yes

Is your pet currently on any flea/tick or heartworm preventatives?(Required)

Yes

Medication

Dose

Frequency

Last given

Need refill?

Yes

Are all of your pets treated with flea medicine?(Required)

Yes

Do you treat your pet with heartworm medication?(Required)

Yes

Brand?

How often?

Last dose?

What are you doing for pet's dental care?(Required)

Does your pet experience any of the following?(Required)

Coughing

Sneezing

Vomiting

Diarrhea

Lethargy

None of the above

Would you be interested in learning more about wellness bloodwork to ensure your pet is healthy?(Required)

Yes

Any lumps or bumps noticed?(Required)

Yes

If yes, where?

Any change in water consumption or urination habits?(Required)

Yes

If yes, please explain:

Any changes in appetite or defecation habits?(Required)

Yes

If yes, please explain:

Have you noticed your pet limping, having difficulty with stairs or rising from a sitting/laying position, showing reluctance to run or jump?(Required)

Yes

Do you have any other behavioral or health concerns with your pet?(Required)

Do you need any of the following today?

Flea medication

Heartworm prevention

Ear cleaner / Shampoo

Pet food

Joint Supplements

Signature(Required)

Make an Appointment

We proudly serve the pets of Colchester, VT, and surrounding areas. We look forward to seeing you and your pet! To request an appointment, please click the button below.

Appointment

Have a Question?

Please complete the form below, and a member of our team will get back to you as quickly as possible.

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Location

5866 Roosevelt Highway
Colchester, VT 05446

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Contact Information

P: 802-878-3713
E: contact@petitbrook.com

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Hours

Mon-Fri: 8:00 AM-5:00 PM
Sat: 8:00 AM-12:00 PM
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *