Medical Questionnaire Form

Name: Lake Hills Veterinary Clinic
Address: 5298 Osage Beach Parkway, Osage Beach, MO, 65065, United States
Telephone: 573-302-8100
Price range: $

Thank you for choosing Lake Hills Veterinary Clinic as your choice! Please fill out the form as completely and accurately as possible.

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Medical Questionnaire Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. Please have all of your pet’s previous records emailed to [email protected] or faxed to 573-302-7142 prior to your appointment. If this is an emergency, or if your pet needs urgent care, please call us at 573-302-8100 for a faster response.

Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Reason for visit: (check all that apply) *

Illness
Annual Physical Exam / Vaccines

Are there any concerns for the following: (check all that apply) *

Eating
Drinking
Weight Loss
Weight Gain
Itching
Scratching
Shaking Head
Vomiting
Diarrhea
Urination Issues
Lameness
Limping
Difficulty Rising
Behavioral Concerns
Skin masses / Tumors (please elaborate below)
Other (please elaborate below)

Please explain

How long have these issues been occurring? *

My pet's lifestyle includes the following: (check all that apply) *

Indoor
Outdoor
Boarding
Grooming
Household with other pets
Travel
Other (please elaborate below)

What kind of food do you feed your pet? How much do you feed? *

Free feed (feed is offered always/ whenever hungry)
Measured amount

Is your pet on any medications or supplements, including flea/tick or heartworm preventives? *

If yes, please list:

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

I give Lake Hills Veterinary Clinic authorization to access veterinary records from previous hospitals as needed. *

I have read and agree

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

Signature *

Clear Signature

Date *

Message

Request An Appointment!

We look forward to seeing you and your furry friend soon! Call us to schedule your next appointment or use our online form.

Appointment

Contact Us

Use the form below, and we’ll get back to you as quickly as possible. If you need immediate assistance during business hours, call us at 573-302-8100. We are available for emergency phone consultations after hours. You can also call the 24 hr ER hospital Horton Discovery at 573-777-3609.

Address

5298 Osage Beach Parkway
Osage Beach, MO 65065

Hours

Monday 8am-6pm

Tuesday-Friday 8am-5pm

Saturday 8am-1pm

We are available for emergencies after hours (Mon-Sun)

Contact

573-302-8100
[email protected]

Name *

First

Last

Email *

Phone

How can we help you? *

Message