Pre-Exam Questionnaire

Name: Somerset Animal Hospital
Address: 715 Rivard St., Somerset, WI, 54025, United States
Telephone: 715-247-2324
Price range: $

Thank you for choosing Somerset Animal Hospital! Please fill out the pre-exam questionnaire below.

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Pre-Exam Questionnaire

Please fill out this form as completely and accurately as possible so we can get to know your pet(s) information before your visit. Please note this form is not to be used for emergency appointments. If you have an emergency please call the Animal Emergency and Referral Center at 651-501-3766.

Exam Date *

Owner/Primary Contact on Account *

First

Last

Pet's Name *

Species *

Dog
Cat
Other

Do you have pet insurance? *

Yes
No
I would like more information

If yes, what company? *

Please visit our Pet Insurance page for more information!

Do you have any concerns you would like address during your visit and when did they start?

Does your pet have any previous medical conditions or diagnosis we should know about?

Do you give your pet Flea and Tick Prevention? *

If yes, what brand? *

Is it given year-round? *

If no, when do you give it? *

Do you give your pet Heartworm Prevention? *

If yes, what brand? *

Is it given year-round? *

If no, when do you give it? *

Does your pet live: *

Indoors most of the time
Indoor/Outdoor
Outdoor only

Explain: *

Is your pet a Hunter? *

If yes, what do they hunt? *

Does your pet go to:

Dog park or Other Pet Gatherings
Boarding or Doggy Daycare
Groomer

Where?

When was the last time your pet was dewormed? *

(Depending on your heartworm prevention, some has dewormer included in it. Example: Heartgard Plus is a monthly dewormer and heartworm prevention)

Do you currently give your pet any medication or supplements regularly or occasionally or as needed? (Please list medication or supplement names, current dose given, and how often they are given)

When was the last time you had a fecal checked on your pet? *

(A fecal test allows our veterinarians to check your pet for intestinal parasites, which may live in your pet’s gastrointestinal tract. Since they are usually hidden from view, the only way to detect the presence of most intestinal parasites and identify them is by doing a fecal test. We recommend a basic fecal panel checked annually. This can be dropped off at any time during business hours or brought with during your next visit. Sample should be collected right away and brought in same day.)

What type/brand of food do you currently feed your pet? *

Is it grain free? *

What is the protein source? *

Chicken
Beef
Other

If other, please list *

Typically, how much, and how many times a day, do you feed your pet? *

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Appointment

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Let's Get In Touch

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Address

715 Rivard St.
Somerset, WI 54025

Contact

P: 715-247-2324
F: 715-706-6100
E: Smallpets54025@gmail.com

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Hours

Mon - Fri: 8:30AM-5:30PM

Sat & Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Phone