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We’re still open despite the construction out front! Contact us for any assistance.

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Corbin Animal Health & Wellness

Patient History Questionnaire Form

Please complete this form as completely and accurately as possible so that we can get to know you and your pet(s) prior to your appointment.

Patient History Questionnaire Form

Owner's Name *

First

Last

Date

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary phone *

Secondary phone

Email *

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

Please describe and frequency of any symptoms

Is she/he having normal stool/urination?

Yes
No

If not, please describe

Is the food/water intake normal?

Yes
No

If not, please describe

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

Is she/he on any medications at this time?If any please list what they have received in the last 24 hours.

Are they on any flea/tick prevention?

Yes
No

They on any heartworm prevention?

Yes
No

Prevention used and last given

Does she/he have any aggression towards people, other animals, or in cage?

Yes
No

In order for safety, please describe

Is she/he up to date on vaccines

Yes
No

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?

Yes
No

Email

Ready for a visit?

Corbin Animal Health & Wellness offers pet wellness care, pet dental care, diagnostic testing, surgery, senior pet care and pain management, hospice and euthanasia, and pet boarding in Corbin, North Corbin, Laurel County, London, Barbourville, Williamsburg, Hopewell, Lily, and the surrounding areas. Easily request an appointment for your pet using our online system on PetDesk. We look forward to meeting you and your furry family members!

We’re here to help.

To learn more about our clinic and services or to schedule your companion’s first appointment, please reach out to us today.

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Our Location

944 Cumberland Gap Pkwy
Corbin, KY 40701

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How to Reach Us

606-528-1744 (phone)
606-528-3389 (fax)
…or email us

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Our Hours

Mon–Fri: 8:00 am – 5:00 pm
Closed on Saturday & Sunday

Visit Our Sister Practice

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Last

Email *

Phone

How can we help you? *

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