Client Check-In - Kindness Animal Hospital - Chippewa Falls, WI

Kindness Animal Hospital

1902 Hallie Road
Chippewa Falls, WI 54729

(715)834-2901

www.kindnessah.com

Client Check-In Form

Name (required)
First Name (required)
Last Name (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Have you visited our hospital previously? (required)
Yes (Welcome back!)
No (Welcome, and please fill out the online new client form and submit prior to arrival)
Pet's Name: (required)

Please tell us below why your pet is coming in for an appointment: (required)

Has your pet had an episodes of vomiting/diarrhea/changes in urination/coughing? Have there been changes in thirst or urination? Any coughing or sneezing?

Is your pet still eating normally? If not, please give details of duration.

Please list your pet's current medications below (name and how often medication is given)?

Do you need any medications refilled? If yes, which medications do you need refilled before your appointment?

Does your pet have a history of vaccination reactions?

Diet Information
Please list below the brand of food you currently feed your pet: (required)

How much do you feed your pet? (ie: 1/2 cup twice daily) (required)

Check below which type of heartworm/intestinal parasite control you apply/give orally to your pet monthly: (required)
Interceptor Plus Chew
HeartGard Plus Chew
Other
My pet does not receive monthly heartworm/intestinal parasite control
If you selected 'Other' (please tell us what heartworm/intestinal product you give/apply monthly):

Check below which type of flea/tick control you apply/give orally to your pet monthly: (required)
Simparica
Nexgard
FrontlinePlus
Revolution Plus (cats only)
Other
My pet does not receive monthly flea/tick control
If you selected 'Other' (please tell us what flea/tick control product you give/apply monthly):


Please check this box if your pet is a feline patient who goes outside

Please check the box below if there are any peanut allergies in your household or if your pet has any food allergies
Do you have any questions or concerns for your veterinarian which you have not mentioned above?


Please check this box if you or anyone in your household has any signs of the COVID-19 virus, recently traveled outside of the country, or been exposed to anyone who has tested positive for the COVID-19 virus
Call hospital phone (715-834-9201) when you arrive to let us know you are here.

Please tell us the make/model/color of the car you will be driving to the appointment (during the COVID-19 pandemic crisis we are practicing a limited contact appointment/drop off policy) (required)


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