Health Form for Telemedicine Exam

A note to our clients: Please be aware that Telemedicine appointments are reserved for non-emergencies and are limited to skin, eye, ear, or gastrointestinal issues that require non-invasive treatment. We may prescribe or refill medications during this appointment depending on your pet’s current health status. This appointment will not serve as an annual exam as the doctor is unable to listen to your pet’s heart or lungs and we are unable to perform any diagnostic lab work if necessary. In order to continue long term medications which require annual lab work, schedule any anesthetic procedure, or for general wellness, please schedule an in-person appointment at your convenience. Telemedicine appointments require that the primary owner (person in charge of making any medical and financial decisions for the patient) is present for the phone call. This is the client’s responsibility. We are not responsible for lack of communication or miscommunication between multiple owners, and we will always refer to the person present for the appointment. Please complete this form and send all required pictures to info@warneravenueanimalhospital.com at least 1 hour prior to your appointment time. The doctor will call you at the time of your appointment, please be prepared to answer. If you should miss the doctor’s call please call the hospital back at (714) 540-5252

Owner's Name*
First Last
Patient's Name*
Primary Contact Number*
Preferred Date of Appointment
Date Format: DD slash MM slash YYYY
Reason for Appointment*
Detailed List of Symptoms*
When did the symptoms first occur?*
Does your pet have any previously diagnosed health conditions which could be pertinent to the appointment?*
What is your pet’s normal diet, portion size, and frequency of meals?*
When was the last time your pet ate?*
What did they eat?*
Has your pet been known to eat anything they shouldn’t? (socks, underwear, rocks, trash/rubbish, etc)*
Is your pet drinking water?*
Amount?*
Is your pet having normal eliminations? (bowel movements and urination) If not, please note concerns*
Is your pet currently on any medications and/or supplements?*
If yes, please list the medications/supplements with milligram amount and frequency if possible:*
When was the last time meds were given?*
Additional comments or concerns at this time:
Please provide any relevant documents/pictures

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 4:30pm
Sunday	8:00am – 4:30pm

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Health Form for Telemedicine Exam

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Health Form for Telemedicine Exam

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