Wellness Questionaire - Powell Animal Hospital - Powell, TN

Powell Animal Hospital

205 Star Mountain Way (Formerly500 W Emory Rd)
Powell, TN 37849



Wellness Questionaire Form

Owner's Name (required)
First Name (required)
Last Name (required)
Phone number where you can be reached: (required)
Phone TypePhone Number (required)
Emergency Contact Number:
Phone TypePhone Number
Address (required)
Street Address (required)
City (required)
State / Province (required)
Zip / Postal Code (required)
Pet's Name (required)

Ideally what would be the best timefor you to pick-up your pet today? (required)

Does your pet spend most of the time indoors, outdoors, or both equally? (required)

indoors only
outdoors only
sometimes indoors, sometimes outdoors
both equally

Is your pet every boarded or groomed? (required)


How often?


Is your pet exposed to other animals, including dog parks and neighborhood walks? (required)


Does your pet travel out of state or go camping with you? (required)


If your pet DOES travel or camp with you, to what parts of the country do you go and how often?

Is your pet exposed to any wildlife, including raccoons, opossums, rats, skunks, squirrel and deer?


Is your pet ever exposed to water, including streams, lakes, rivers, or standing water in yards?


In the past month has your pet had any vomiting or diarrhea? Which one and how often?

In the last month, has your pet had any coughing or sneezing?

Any changes in eating habits in the past 3 months?

What type of food and treats does you pet eat and how much?

Any changes in water consumption or urination in the last month?


If you answered "yes", what changes have occurred?

Any changes in behavior the past three months?

Is there anything specific that you would like addressed with your pet?

Does your pet receive flea, tick, and/or Heartworm medication each month?


Does your pet take any other medications on a regular basis?

Would you like to be called and given an estimate for today's services?


What is (are) the best phone number(s) to reach you today?

Powell Animal Hospital Drop-off Policy:
Please note that we require all pets staying with us for the day to be current on vaccinations and to have had a negative fecal examination within the past 6 months. If your pet is due vaccinations, your pet will be vaccinated before treatments are performed. Additionally, your pet must be free from both external and internal parasites. If treatment for parasites is necessary, this will be performed at your expense.
By submitting this form, I authorize the doctors at Powell Animal Hospital to perform the diagnostics and treatments that they feel necessary up to the amount I listed above. I understand that if additional services are necessary, I will be contacted by a doctor so that we can discuss these procedures and their cost. If I cannot be reached, I give my permission for the doctors to perform any necessary emergency treatments that may be needed to stabilize a life-threatening condition. I agree to assume all financial responsibility for these treatments in the case of an emergency.
I have read the above statement, and I - (required)


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