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Online Forms

Patient History Questionnaire

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

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Pet History Questionnaire Form

Client Information Update

Owner's Name *

First

Last

Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Today's Pet History

Patient Name

Why is your pet visiting today?

What other symptoms is she/he having? (Check all that apply and how long it has been occurring)

Behavioral Change
Itchiness
Scratching
Breathing Problems
Lethargic
Shaking head
Coughing
Limping
Sneezing
Eye disorder
Loss of balance
Vomiting
Gagging
Scooting
Weakness

Please describe any symptoms and their frequency:

Are they having normal stool/urination?

Please describe:

Is their food/water intake normal?

Please describe:

What is their normal diet? (Please describe what they eat throughout the day)

List any medications your pet has taken in the past 24 hours:

Are they on any flea/tick prevention?

Preventions used:

Are they on any heart worm prevention?

Last given:

Do they have any aggresion towards people, other animals, or in cage?

For safety reasons, please describe:

Are they up to date on vaccines?

When/Where:

Is there anyone in the household that has a peanut allergy that would require us to not potentially use peanut butter during an exam to make a pet focused?

Ready to visit?

If you are searching for a trusted veterinarian in Corbin, Woodbine, North Corbin, or the surrounding areas, look no further than Corbin Animal Clinic. We are always accepting new patients and would be honored to be entrusted with your companion’s care.

Appointment

Have a question?

Fill out our online form, and a member of our team will get back to you as quickly as possible.

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Address

1220 Cumberland Falls Hwy,
Corbin, KY 40701

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Contact

Email: [email protected]
Phone: 606-523-1099

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Hours

Mon-Fri: 8:00 am – 5:00 pm
3rd Wednesday of Each Month: Closed from 12 pm – 1:30 pm for Staff Meetings
Sat: 8:00 am – 1:00 pm
Sun: Closed

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Name *

First

Last

Email *

Phone

How can we help you? *

Phone