Forms & Requests Appointment Request Form Appointment Request Form We frequently check email and faxes, and our front desk staff will be in touch promptly. However, please allow one business day to respond in setting up your appointment. Same day appointments are best scheduled by calling the office directly at 317-336-8900. Your Name * Your Pet's Name * Pet Type: Canine Feline Other Nature of Issue for Appointment Routine/Checkup/Vaccinations Illness/Injury/Problem Re-evaluation/Progress Exam Nail Trim/Suture Removal/Other Technician Services Grooming/Bathing Desired Date of Appointment: Desired Time A.M. P.M. Doesn't Matter Phone Number * Email Additional Information * If you are human, leave this field blank. Send Prescription Refill Form Prescription Refill Form Please note that this form can be used to dispense medication precribed by our office. Please allow one buiness day for processing. Your Full Name: * Pet's Full Name: * Breed -- Breed -- Dog Cat Other Prescription Drug Name: * Strength (If Known) Quantity or Volume: * How are you giving the meds dosage? Desired Time of Pickup? A.M. P.M. Best Contact Phone * Additional Info or Comments * If you are human, leave this field blank. Send Behavioral Questionnaire Behavioral Questionnaire Your First Name * Your Last Name * Your Pet's Name * Breed of Dog/Cat * Age of your Pet * Sex Male Male, Neutered Female Female, Spayed Please describe in as much detail as possible what the primary behavioral problem or problems are. Please include how long the behavior issues have been occurring, where it occurs, who (if anyone) is present when it occurs, and what the trigger may be (if known). * Please describe the MOST recent incident that exemplifies the behavior problem(s) Please include any additional information you feel may be helpful in further diagnosing the problem. Include any previous treatments, if appropriate If you pet is spayed/neutered, at what age were they spayed/neutered? If you pet is spayed/neutered, for what reason? If you pet is spayed/neutered, did you notice any behavior changes afterwards? If you pet is NOT spayed or neutered, do you plan to breed them? How old was your pet when you first acquired him/her? Has your pet had other owners? If so, how many previous owners and why were they re-homed? * How long have you had this pet? Where did you get this pet? (select all that apply) * Stray/Found Breed Specific Rescue Friend Breeder Humane Society/Rescue/Shelter Pet Store Newspaper Ad/Facebook Other:Other: What is the primary purpose for getting this pet? (select all that apply) * Adult's Pet Show Dog Farm/Outdoor Dog Hunting Dog Family Pet Children's Pet Breeding Obedience/Agility Work Watch/Guard Dog Service/Working Dog Other:Other: What is the average number of hours your pet is left alone each weekday? * Is your weekday schedule consistent? * Consistent Varies Where is the pet when he/she is left alone? (select all that apply) * Cage Basement Outside & Tied Out Loose in Yard Confined in a Room Garage Loose in a Living Space Outside in a Kennel Outside and Loose (Esp. Cats) OtherOther What percentage of the day does your pet spend inside? * What percentage of the day does your pet spend outside? * What kind of living situation do you have? * Apartment Townhouse/Condominium House with Large Yard House with Small Yard Farm OtherOther Where is your pet at night? (select all that apply) * Cage Confined in a Room Loose in the Living Area Basement Garage Bedroom On Someone's Bed Outside OtherOther How many times is your dog or cat let outside per day? * 1 2 3 4 5 6 7 8+ If your pet is walked, what is the average time for each walk (in minutes)? How many meals does your pet get each day? * 1 2 3 4 Fed Free-Choice How often is your pet fed treats (cat treats, dog biscuits, chews) each day? * 1 2 3 4 OtherOther How often do you feed your pet snacks from the table (i.e. human food) each day? * Never Rarely Sometimes Often Does your pet have any preexisting medical issues? If yes, please explain. Are there any other pets in the household? If yes, please list all pet's name(s), breed(s), sex, age. Has your household had any significant changes since adopting this pet? If so, how? (select all that apply) * No significant changes Death of a human family member Death of a pet family member Divorce Marriage New pet added to the family Baby born Family moved Child moved Family schedule change (loss or gain of a job) OtherOther Have you had dogs before? * Yes No Have you had a cat before? * Yes No How often do you play with toys or play games with your pet indoors on a daily basis? * 1 2 3 4 5 6+ How often do you play with toys or play games with your pet outdoors on a daily basis? * 1 2 3 4 5 6+ Please describe in some detail, how you prepare to leave the house when the pet will be left alone. For example, do you ignore your pet, do you seek it out and say goodbye, do you make a fuss over it, etc? What does your pet do as you prepare to leave? * How would you describe your pet's personality? (select all that apply) * Friendly to owner/people they know Friendly to strangers Shy to strangers Anxious Fearful of its environment Aloof Aloof to strangers Happy, outgoing Hyper-excitable Fearful of noises Aggressive to owner/people they know Aggressive to strangers/people they know Inhibited Supersubmissive Unsure OtherOther Does your DOG regularly (at least weekly) engage in the following: * No When owner is present When owner is absent Unsure Excessive barking/whining * No When owner is present When owner is absent Unsure House soiling * No When owner is present When owner is absent Unsure Destructive chewing * No When owner is present When owner is absent Unsure Self licking/chewing * No When owner is present When owner is absent Unsure Digging * No When owner is present When owner is absent Unsure Pacing, repetitive behavior * No When owner is present When owner is absent Unsure (Cats only) How many litter boxes do you have? 1 2 3 4 5 6+ (Cats only) What kind of litter material do you put in the litter box(es)? (select all that apply) Clump-able Playground sand Potting Soil Plain Clay Deodorized Anything that is on sale Ashes Gravel/rock Sawdust/Wood Chips What Husks Recycled/Pelleted Newspaper Shredded paper or paper toweling None, empty box OtherOther (Dogs only) Do you use the following training aids? (select all that apply) Off Leash Only Flat Collar Halter Choke Chain Pinch Collar Shock Collar If you are human, leave this field blank. Submit Feline Inappropriate Urination Questionnaire Feline Inappropriate Urination Questionnaire Your Name: * Pet's Name: * Email: * Pet's Age: Sex -- Sex -- Male Female Neutered: Yes No Size, Weight, Coat Length: # of Cats in Household: Duration of House-soiling (days, weeks, months, years): Approximately When did the Problem Start? How often does your cat urinate out of the litter box? How often does your cat defecate out of the litter box? If you are human, leave this field blank. Continue
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