Gilbert Veterinary Hospital Curbside Patient History Form

Please be advised patients will be greeted in our parking lot as all care is being provided curbside. Please call us at 480-963-1815 when you arrive

"Veterinary care is an essential part of our community, and we want to assure you that our hospital is open and will continue to provide services at this time. We also want to work with you to limit direct contact in order to focus on safety for everyone during this pandemic. Accordingly, we have moved to curbside service only at this time and are not allowing non-employee's into the building. We have adjusted our current operations based upon the recommendations of the American Veterinary Health Medical Association, CDC and the World Organization for Animal Health. The following precautions are taken to protect you, our doctors and our staff from potential spread of Coronavirus COVID-19 while continuing to provide care. In an effort to streamline this service and be respectful of your time we would ask that you complete this history form before your visit. This will allow our team to be prepared to handle your pets concern as quickly and safely as possible. We truly appreciate your understanding and support during these uncertain times. Your Gilbert Veterinary Healthcare Team appreciates your support. "
Full Name *

First Name Last Name
Pet Name *
We would ask that if you are able, please wear a mask while handing your pet off to one of our team members.
Phone *

Area Code Phone Number
E-mail *
Vehicle description & color *
make, model and color of vehicle that you will be arriving in
If you already have an appointment scheduled, what date and time is your appointment scheduled for? Please call the office to schedule if you have not already scheduled an appointment.

Month Day Year Hour Minutes AM/PM Option
Have you or anyone you have come into contact with been exposed to COVID or shown signs of sickness in the past 10 days? *

Yes No
Reason for visit *
Please list your concerns
Medications *
Please list your pets current medications and last dose given
Diet and amount fed *
Please list your pets current diet, amount and frequency fed.
Please list any additional services, medication or products needed. *
To keep everyone safe and minimize exposure is there anything else that you are in need of while you are here for your visit? Although online pharmacies and our local stores carry many products we are seeing long waits, delayed shipping and unnecessary exposure. GVH carries and has available most pet medications and prescription diets for your convenience. .
Eating *
Drinking *
Vomiting/Diarrhea? *
Is your pet coughing/sneezing? *
Signature

Clear
Diarrhea *

Yes No
Eating *

Normal Increased Decreased
Sneezing *

Yes No
Vomiting *

Yes No
Drinking *

Normal Increased Decreased
Urination *

Normal Increased Decreased
Coughing *

Yes No
Stool *

Normal Soft Diarrhea
Current Pain Level *

(0) - No pain (1) - May be in pain (2) - Mild pain (3) - Moderate pain (4) - Significant pain (5) - Severe pain
Should be Empty: