(512) 267-7387
lvanimalclinic@gmail.com

Online Pharmacy
Emergency Clinic

(512) 267-7387
lvanimalclinic@gmail.com

Online Pharmacy
Emergency Clinic

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Wellness Drop Off Questionnaire

Please complete this form BEFORE you drop off your pet.

indoor cat looking out of window

Wellness Drop Off Questionnaire

Please fill out this form as completely and accurately as possible.

Name *

Pet Name *

Best phone number to reach you today *

Okay to text? *

Yes
No

Reason for today’s visit *

Has your pet had any of the following symptoms?

If yes, please explain (frequency, duration, etc.)

Change in appetite *

Yes
No

If yes, explain (frequency, duration, etc): *

Change in drinking *

Yes
No

If yes, explain (frequency, duration, etc): *

Diarrhea *

Yes
No

If yes, explain (frequency, duration, etc): *

Vomiting *

Yes
No

If yes, explain (frequency, duration, etc): *

Coughing *

Yes
No

If yes, explain (frequency, duration, etc): *

Sneezing *

Yes
No

If yes, explain (frequency, duration, etc): *

Change in urination *

Yes
No

the

If yes, explain (frequency, duration, etc): *

Change in activity level *

Yes
No

If yes, explain (frequency, duration, etc): *

Allergies to food/medications *

Yes
No

If yes, explain (frequency, duration, etc): *

Cats only:

Does your pet go outside?

Yes
No

If yes, explain (frequency, duration, etc): *

Any other questions or concerns for the doctor? *

What diet does your pet eat? (Please list the brand, volume, and frequency) *

Is your pet currently on any medications or supplements? (Including heartworm and flea prevention) If so, what and when were the last doses given? *

Do you need refills of any medications? If so, please list the name and quantity needed: *

Would you like an estimate prior to services being performed? *

Yes
No

In the unlikely event of an emergency, would you like us to perform CPR on your pet? *

YES, I authorize CPR or other procedures necessary for the wellbeing of my pet.
NO, I decline any emergency treatment if complications develop.

Signature *

Clear Signature

Date *

Ready to Visit

We proudly serve the pets of Lago Vista, Leander, Cedar Park, Marble Falls, and beyond. We look forward to seeing you and your pet! Book an appointment by clicking the button below.

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Get in Touch

20711 FM 1431
Lago Vista, TX 78645

Phone: (512) 267-7387
Email: lvanimalclinic@gmail.com

Hospital Hours

Monday: 7:30 am – 5:30 pm
Tuesday: 8:00 am – 6:00 pm
Wednesday: 8:00 am – 5:30 pm
Thursday: 8:00 am – 6:00 pm
Friday: 8:00 am – 5:00 pm
Saturday: 9:00 am – 12:00 pm
Sunday: Closed

Emergency Clinic

Phone: (512) 817-3474

After-hours emergencies are referred to the Crystal Falls Veterinary Emergency in Raider Way, Leander.

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