Check in form

Are you in the waiting area? *

Yes
No, this is for upcoming appointment

A cat should be in a carrier, and dogs should be on a leash, for safety of other pets and pet owners *

I will bring my cat in a carrier
I will bring my dog on a leash
I have a cat, but no carrier

If you are bringing the cat in for appointment, and do not have a carrier, please advise the staff, so we can provide you one for the duration of the appointment, if there is one available.

Pet Name and Last name *

Temperament *

Good/Normal
Anxious/Nervous
Observe caution
Aggressive/Reactive
I am not sure, use muzzle if needed

Date of appointment

Lifestyle of the pet *

Indoors (does not go outside at all).
Outdoors, supervised (leashed or watched).
Outdoors, unsupervised (off leash/unobserved activity).
Mixed, supervised and unsupervised activity.

Please select type of visit *

Vaccines/Wellness
Medical problem
Health certificate for travel

Please verify the travel requirements for your pet, for the destination country, including vaccine requirements, parasite treatments. You can visit CFIA website or call them to confirm travel requirements. We do not provide or confirm these travel requirements.

ALL vaccines visits will carry wellness check fee as minimum plus the vaccine(s), please do not argue with staff about it.

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Date / Time of travel/flight

Country of destination

Home address (if different from one in the file)

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Do have CFIA appointment booked?

CFIA - Canadian Food Inspection Agency

Date / Time of CFIA appointment

Date

Time

Please enter date and time of CFIA appointment if you have already booked it.

Would you be interested in a free trial of insurance if your pet qualifies? *

Eating *

Drinking *

Urination *

Activity levels *

Stools *

Main medical concern(s), if not included above

Breathing difficulty
Coughing
Sneezing
Check teeth
EAR problem, RIGHT
EAR problem, LEFT
EAR problem, both
EYE problem, RIGHT
EYE problem, LEFT
EYE problem, both
Limping, FRONT LEFT leg
Limping, FRONT RIGHT leg
Limping, HIND LEFT leg
Limping, HIND RIGHT leg
Limping, NOT SURE which leg
Mass/Growth/Lump
Scooting
Skin problem, itchy
Skin problem, not itchy
Vomiting

Mass/Growth/Lump Selected

Location, duration, whether growing or bothering

Additional info, if not in list above (Please keep it concise)

Please provide information about medical problem, onset, progression

Add on

Anal gland expression
Ear cleaning
Nail trim

Check all that apply (coughing/sneezing/breathing difficulty)

Environmental dust/smoke present.
May have access to dusty spots in the house.
Eats grass or chews on sticks.
Has access to fluffy toys.
Tries to kill his toys.

Check all that apply (abnormal stools)

Drinks water from puddles.
Environmental dust/smoke exposure.
Eats grass (park/backyard).
Eats garbage or stuff from sidewalk.
Gets table food occasionally.
Gets table food regularly.

Is your pet on a flea preventive? *

Do you wish to pick up flea preventive today?

Parasites are organisms that feed on (ectoparasites) or within (endoparasites) other animals. Fleas and ticks are the most well-known offenders, but they are only part of the picture. Other common parasites include mites, lice, heartworm and a multitude of intestinal and other parasites.

Do you wish to pick up deworming for your pet?

Dogs can be hosts to worms and other parasites. Animals that sniff, slurp, lick, and gobble anything in their paths, including dirt, trash, and poop, are bound to pick up parasites. All the things they do with their mouths -- groom, kiss, wrestle, and other social habits -- can pass along unwanted guests to playmates and companions, canine and human alike. In puppies, it can slow down weight gain and can affect your puppy's growth. Deworming is recommened occasionally or frequently depending on their habits.

Areas affected (Skin problem, itchy)

Ears
Front feet
Back feet
Hind end
In between back legs
Armpits
Face
Eyes
Back
Shoulders
Other

Select all locations that apply

Location of skin problem (Skin problem, not itchy)

Ears
Front feet
Back feet
Hind end
In between back legs
Armpits
Face
Eyes
Back
Shoulders
Other

Select all locations that apply

Which vaccines are due?

If you do not know, please bring your vaccination card/certificate with you, our staff can help you figure it out

Current diet/supplements *

Please mention dry as well wet foods along with supplements that you use for your pets.

Medical history/Previous clinic

Please enter previous medical problems that have been diagnosed for your pet. Also list current medicines.

Please collect a stool sample for your pet. You can collect it in any clean dry Tupperware container or a sandwich bag.

A urine sample needs to be brought in so it can be sent out to lab for testing. Testing will help us provide more specific therapy for your pet. Urine sample can be collected in a clean plastic tupperware container or clean sandwich bag for dogs.

For cats, use some sran wrap on top of the litter to collect clean sample when your cat uses the litter box. Alternatively, you can stop by our clinic and pick up urine collection kit at no charge.

Check in form

Please fill out the check-in form if you are bringing your pet to see us for a medical problem. Only fill it within 24 hours of your appointment.

Please verify the travel requirements for your pet, for the destination country, including vaccine requirements, parasite treatments. You can visit CFIA website or call them to confirm travel requirements. We do not provide or confirm these travel requirements.

ALL vaccines visits will carry wellness check fee as minimum plus the vaccine(s), please do not argue with staff about it.

Please collect a stool sample for your pet. You can collect it in any clean dry Tupperware container or a sandwich bag.

A urine sample needs to be brought in so it can be sent out to lab for testing. Testing will help us provide more specific therapy for your pet. Urine sample can be collected in a clean plastic tupperware container or clean sandwich bag for dogs.

For cats, use some sran wrap on top of the litter to collect clean sample when your cat uses the litter box. Alternatively, you can stop by our clinic and pick up urine collection kit at no charge.

Hume Park Animal Hospital

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