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office@whitehillsanimalhospital.com
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Appointment

Home
About
- Our Story
- Our Team
- Photo Gallery
- FAQs
Services
Resources
MyVetStore
Contact
Appointment

Canine Problem Form

Save time during your canine problem appointment. Complete your required form online from any device at any time before your visit.

canine-problem-form-banner

Canine Problem Form

Please fill out this form completely and accurately so we can learn as much about your concern as possible.

What is your FIRST and LAST NAME? *

First

Last

What is your PET'S NAME? *

What is your phone number? *

What is your concern? *

When was the problem first noticed? *

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Are any other contact animal affected?

Yes
No

Please Specify

Has anything been given at home to treat the problem?

Yes
No

Please Specify

What meds are currently being given to your pet, and when was the last dose given?

Does your dog have a cough? If coughing, when did it start? When does it occur? Is it getting worse or resolving?

Is your dog sneezing? If sneezing, when did it start? When does it occur? Is it getting worse or resolving? Is there a discharge? If so, what color:

Is your pet vomiting? If vomiting, when did it start? When does it occur (how soon aftereating)? Is it getting worse or resolving? Is there blood in the vomitus? What is vomited? Any history of dietary indiscretion?

Has your pet had diarrhea? If no please answer no to the following questions

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When did it start?

Is there blood or mucous in the feces?

When does it occur?

What is the fecal consistency?

Is it getting worse or resolving?

Any history of dietary indiscretion

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Any history of tremors/seizures?

Yes
No

Please Specify

Any new or changed lumps/bumps/skin lesion?

Yes
No

Please Specify

Any changes in urination?

Yes
No

Please Specify

Any history of scratching/ hair loss?

Yes
No

Please Specify

Any changes in thirst?

Yes
No

Please Specify

How much water consumed daily?

Food

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Does your dog have a good appetite?

How often and how much is fed?

Can they have treats while they are here in the clinic?

What food is fed?

Are any table scraps fed?

When will your dog have last eaten before its appointment? *

What supplements are given, and when was last dose given?

Any changes in...

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Vision?

Hearing?

Temperament?

Any changes in mobility (gait changes/stiffness/sore to touch)?

Yes
No

Please Specify

Lifestyle

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History of boarding?

Plans to travel outside London?

Plans to board?

Has your pet been to the leash free park?

History of travel outside London?

Will your pet go to the leash free park in the future?

Other observations of concern?

Are there any specific areas on your pets body that they are very nervous of having touched/ don't like having handled?

We recommend Interceptor Plus for heartworm prevention, and Credelio for flea/tickprevention, unless your pet requires a topical medication. If Heartworm prevention is elected, we do require an up to date 4DX test.

Yes my pet needs heartworm prevention dispensed today
Yes my pet needs flea/tick prevention dispensed today
No my pet does not need heartworm prevention dispensed today
No my pet does not need flea/tick prevention dispensed today
My pet receives a topical medication

How many doses of prevention would you like today? (We recommend year round prevention) *

Questions for COVID19 screening:

Have you, or someone you live with, been sick with symptoms associated with Covid19 in the last 5 days?

If your dog is vomiting, having diarrhea, or coughing, please keep them inside of your vehicle until a staff member comes to collect them

I understand

Phone

Make an Appointment

You can schedule an appointment by clicking the button below.

QUESTIONS?

We look forward to hearing from you!

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Address:

2111 Aldersbrook Rd.
London, ON N6G 3X1

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Contact Information

Phone: (519) 473-1182
E-mail: office@whitehillsanimalhospital.com

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

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Hours

Mon & Wed: 8:00am – 7:30pm
Tues, Thurs & Fri: 8:00am – 6:00pm
Sat: 8:00am – 12:00pm
Sun: Closed

Our phone lines are off for lunch daily from 12:30 pm – 1:30 pm.
The phones are turned off 1 hour prior to close.
On Saturdays, our phones are turned off at 10:00am.

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