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520.886.1125
180 N. Harrison Road
Tucson, AZ 85748
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Mon-Fri 7:30am-5:30pm
Sat 9:00am-4:00pm
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Home
About Us
Our Team
Blog
Careers
Services
Pet Physical Exams
Pet Wellness Plans
Pet Individualized Preventive Veterinary Care
Pet Dental Care
Pet Safer Surgery
Pet Cold Laser Therapy
Pet Digital Dental X-rays
Pet Digital body X-rays
Pet Continuous Glucose Monitoring
Pet Fear-Free Practice
Pet Cat Friendly Practice
Patient Forms
New Patient Registration
Prescription Request
Medical History
Drop Off/Hospitalization Consent
Surgical Anesthesia Consent Form
TeleMed Consult
Dental Treatment Consent Form
Health Certificate Information
Pet Resources
Contact
Book Appointment
TeleMed Consult
Medical History Questionnaire
Please enable JavaScript in your browser to complete this form.
Date
Pet Name
*
Has this pet had an in-clinic Doctor exam within the last year?
*
Yes
No
** Special (temporary) Gubernatorial COVID-19 Order allows veterinarians to establish a Veterinary-Patient-Client Relationship via electronic means. A "Veterinary-Client-Patient Relationship" usually requires an in-person knowledge of the patient's physical condition as well as a knowledge of how it is cared for in its environment, requiring an in person doctor examination within the year. If we have not seen your pet in person within the year, we may still be able to assist. If we cannot, our Doctor may recommend an in-clinic examination to adequately care for your pet. Please submit this form and we will try to help as expeditiously as possible.
Type of Pet
Dog
Cat
Ferret
Rabbit
Rat
Hamster
Hedgehog
Other
Age
Color
Does your Pet have Health Insurance?
*
Yes
No
** I'd like some information on Health Insurance
What is your concern about your pet?
Medical history
Please fill in the health questions below so we can be sure to cover everything while your pet is here. This also helps us keep your pet's record up to date between visits!
Lifestyle
*
Walled, Cultivated Yard
Open desert yard
Exposure to desert animals
Strictly indoors
Swims
Goes to Parks/ Groomers/ Boarding Kennels
Travels outside Tucson
Indoors Only Cat
Other
Please check all that apply
Please explain additional details of your pet's environment, if you like
Diet/ Nutrition
*
Over the Counter Pet food
Grain Free Pet Food
Prescription Food
Home Made diet
Pet snacks/ treats
Human snacks/ treats
Please check all that apply
Brand of food:
How is your Pet's Appetite/ Drinking?
*
Normal
Abnormal
Please explain Abnormalities in Eating or Drinking
How are your Pet's Eliminations (Urine and Stool)?
*
Normal
Abnormal
Please explain abnormalities in your pet's Eliminations
Has Your Pet Shown Any of the Following Signs?
*
Vomiting
Coughing
Sneezing
New Lumps
Excess Scratching/ Chewing on body
Shaking/ Scratching Ears
Limping/ Stiffness/ Difficulty Rising
Behavior Changes: less active/ more vocal/ more reclusive etc
None of the Above
Please explain details of this condition
Please list any Medications, Supplements your pet is Currently Taking
Remember Heartworm Preventives, Flea/Tick Protection, Vitamins and Natural supplements. Type "none" if your pet is not taking any medications, supplements, vitamins, parasite preventions.
Paragraph Text
Telemedicine Consult Limitations
I Understand that: This Telehealth consult will not be as thorough as an exam in person. There is a fee of $25 upon completion of the Telehealth consult. This fee is not refundable. However, If it is determined, during this consult, that my pet cannot be sufficiently treated without an exam in-clinic, the amount of the Telemedicine consult fee will be applied to the in-clinic exam when it occurs. (If my pet is not presented in-clinic for the issue after recommendation by the veterinarian, no credit or refund will be provided.) All efforts will be made to connect with you on schedule, however, circumstances in the clinic may cause our Team to run behind, just as if you were here in person. Please be patient. If you should have concerns, please call to check on your appointment status. If this consult is interrupted due to technological difficulties, it will be restarted. Other team members may be within hearing of this consultation during video Ccnferencing. These people will all maintain confidentiality of any information overheard. However, if, at any time, you would like more privacy, we will accommodate. If you have any additional questions about the Telemedicine consult process, please call our office at 520 886-1125
Name*
By typing my name below I agree to the terms of the Telelmedicine Consult Limitations described above.
Name
*
First
Last
Submit