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Patient History Form

Please fill out the form below ahead of your appointment

To help us get to know you and your pet better, please answer these questions before your appointment.

About You and Your Pet

Your pet's sex
Is Your Pet Neutered?

Please Tick Appropriate Answer

Appetite
Drinking
Coughing
Sneezing
Activity Level
Vomiting
Bowel Function
Urination

If Your Pet Is Unwell, Please Complete The Following

 

If some of these fields don't apply to your pet, please bypass them by entering N/A

If your pet is not ill and these fields don't apply to your pet, please tick 'not ill' below

Medication and Food

Would you like us to prescribe flea and worming treatment for your pet?
Do you wish to purchase any food at the time of your pet's appointment?
25% off stocked brands, life-stage and prescription for PHC members
Does your pet require a repeat of any chronic medication(s) or supplements?
20% off selected chronic medications and 10% off supplements/pet shop sales on PHC

Diet History

How active is your pet normally?
How Would You Describe Your Pet's Weight?
Where does your pet spend most of their time?
*If you feed by volume, what size measuring device do you use? *If you feed tinned/canned food, what size tins/cans/trays?
Do you give any dietary supplements to your pet (for example: Vitamins, Glucosamine, Essential Fatty Acids, or any other supplements)?

Additional Questions Relating to Your Pet's Appointment

Is Your Pet Insured?
If this information is unknown, then please check your policy documents, or contact your pet’s insurance provider to enquire. We are unable to offer direct claims for costs incurred, without this information.

Are Any Other Procedures Required? (Please Note Free of Charge if on PHC)

Clip Nails
Empty anal glands
Would you like to join our Pet Health Club?

New Puppy, Kitten, or Bunny?

If you do not have insurance for your pet, would you like us to issue 4-week's free immediate veterinary cover through Petplan?
*Please note, a link will be sent to you via email/SMS and this must be activated within 24 hours of receipt, to receive the maximum free cover available. The cover-note shall be issued following your pet’s appointment with the vet.
If yes - please enter their microchip number.
Have they received any Vaccinations so far?
If yes - please bring their vaccination card to their first appointment.
If yes - please enter product(s) and date(s) received.
If yes - please provide brief details.
Security Question
 
 
 

Practice information

Fazakerley

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  • Mon
    9:00am - 6:30pm
  • Tue
    9:00am - 6:30pm
  • Wed
    9:00am - 6:30pm
  • Thu
    9:00am - 6:30pm
  • Fri
    9:00am - 6:30pm
  • Sat
    9:00am - 12:30pm
  • Sun
    Closed

Emergency Details

Please call:

0151 480 2040
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Find us here:

The Lodge Aintree Hospital Gate Longmoor Lane Fazakerley L9 7LQ
get directions with Google Maps
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Please call this number for emergencies:

0151 480 2040

Wavertree

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  • Mon
    9:00am - 6:30pm
  • Tue
    9:00am - 6:30pm
  • Wed
    9:00am - 6:30pm
  • Thu
    9:00am - 6:30pm
  • Fri
    9:00am - 6:30pm
  • Sat
    Closed
  • Sun
    Closed

Emergency Details

Please call:

0151 480 2040
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Find us here:

19 Church Road Wavertree Liverpool L15 9EA
get directions with Google Maps
Back

Please call this number for emergencies:

0151 480 2040