Drop Off Questionnaire

Lyndon Veterinary Clinic

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-8170

lyndonvet.com

Drop Off Questionnaire

Pet's Name, Your Last Name (required)

First Name (required)	Last Name (required)

Activity level normal? (required)

yes
no

Eating and drinking normally? (required)

yes
no

Did he/she eat today? (required)

yes
no

If so, what time?

What brand of food has he/she been eating at home? (required)

How much food is he/she eating? (required)

Does he/she receive any treats? (required)

yes
no

If so, what kind?

Any vomiting? (required)

yes
no

If so, how often? Duration? How long after eating? What does the vomit look like?

Any diarrhea or constipation? (required)

yes
no

If so, how often? Duration? Appearance of stool (if abnormal)? Is there blood in it?

Any coughing? (required)

yes
no

If so, how many times per day? Duration? Cough anything up?

Any sneezing? (required)

yes
no

Any changes in mobility? (required)

yes
no

If so, please describe.

Urinating normally? (required)

yes
no

If not, what is abnormal? Any accidents in the house?

Any scratching? (required)

yes
no

If so, on a scale of 1-10 with 10 being unbearably itchy, how itchy?

1
2
3
4
5
6
7
8
9
10

Any fur loss noted? (required)

yes
no

What medications is he or she receiving and how often? (required)

Were any given this morning? If so, which ones and at what times? (required)

Is your pet receiving heartworm preventative? (required)

yes
no

If so, what kind?

Is your pet receiving flea and/or tick preventative? (required)

yes
no

If so, what kind?

Any other concerns we should know about?

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HOURS

Day	Open	Close
Monday	7:00am	6:00pm
Tuesday	7:00am	6:00pm
Wednesday	7:00am	6:00pm
Thursday	7:00am	6:00pm
Friday	8:00am	1:00pm
Saturday	Closed	Closed
Sunday	Closed	Closed

LOCATION

CONTACT

Phone: 315-445-8170

Email: contact@lyndonvet.com