Curbside Care – MacCormick Veterinary Services

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Curbside Care: Medical History Form

Date:*
dd/mm/yyyy
Owner's Name
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Pet Information
Pet's Name*
Species*
if other please specify
Breed (if known)
Sex
Color
Date of Birth or Age (if known)
Pet Health - Reason for Visit
Describe your concern*
How long has this been going on?*
Days/Weeks/Months
What are you currently feeding your pet?*
food/treats
How is their appetite?*
poor/good/excellent
Are you currently giving any medications or supplements?*
- yes
- no
Please specify*
name/dose/last given
Any coughing or sneezing?*
- yes
- no
Please describe*
Any vomiting or diarrhea?*
- yes
- no
Please describe*
Have they gotten into anything? Eaten anything unusual?*
- yes
- no
Please describe*
Is your pet indoors only? (Cats)
Any environmental changes?*
Describe their behavior*
lethargic/normal/hyperactive
Any changes to thirst?*
increased/normal/decreased
Any changes to urination?*
increased/normal/decreased
How are their bowel movements?*
normal/abnormal
When was their last bowel movement*
Does your pet receive tick prevention medication all months of the year as recommended in this area?*
- Yes
- No
COVID-19 Screening
1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Please check any symptoms that apply to you.*
- Fever or chills
- Difficulty breathing or shortness of breath
- Cough
- Sore throat, trouble swallowing
- Runny nose/stuffy nose or nasal congestion
- Decrease or loss of smell or taste
- Nausea, vomiting, diarrhea, abdominal pain
- Not feeling well, extreme tiredness, sore muscles
- I am experiencing none of the above symptoms
2. Have you travelled outside of Canada in the past 14 days?*
- Yes
- No
3. Have you had close contact with a confirmed or probable case of COVID-19?*
- Yes
- No

Contact Us

MacCormick Veterinary Services
5841 Highway 34
Vankleek Hill , Ontario
K0B 1R0

Phone: (613) 678-3678
Fax: (613) 678-5092
Email: [email protected]

Hours of Operation

Due to COVID-19 we are open Mon-Fri from 8:00am – 5:00pm

Monday 8:00am – 5:00pm
Tuesday 8:00am – 5:00pm
Wednesday 8:00am – 5:00pm
Thursday 8:00am – 5:00pm
Friday 8:00am – 5:00pm
Saturday Closed
Sunday Closed

Emergencies

Alta Vista Animal Hospital
Open 24 hours

Phone: 613 731 6851

Address:
2616 Bank Street
Ottawa, Ontario
K1T 1M9

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MYVETSTORE
New Clients
About Us
FAQs
Services
Pet Health
Links
Call Us At (613) 678-3678