Pre-Appointment Questionnaire in Placerville, CA

Please complete before your visit.
Please provide all information as completely as possible. Thank you for choosing Pleasant Valley Pet Clinic .

Name*

First Last

Phone*

Email*

Pet's Name*

Pet's Species*

Cat
Dog

Reason for visit

Please note: If your pet is being seen for an annual visit or has any gastrointestinal issues(vomiting, diarrhea, loose stools), please bring a fresh fecal sample to their appointment. If your pet has urinary concerns, please do not let them urinate for 1 hr before the appointment.

Is your pet taking any medication or supplements? Please list all medications and current dosing.*

Yes
No

If you need a prescription refill, please fill out our prescription refill form here.

What brand of food and how much are you feeding your pet? Please include any treats, dry/canned food, and human food.

Do you have any other concerns about your pet that you would like to discuss at their appointment?

Late and Cancellation Policy: Pleasant Valley Pet Clinic has a 10-minute late policy, which states: If you're more than 10 minutes late for your appointment, you'll be marked as a no-show which could result in a reschedule for your pet’s scheduled services. We also have a strict cancellation/rescheduling policy. If you need to cancel or reschedule your pet's appointment we require 24 hrs' notice so that we may accommodate other sick pets that need care.

Consent*

I have read and understand this policy.

Signature*

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Email

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