Mobile Patient Check In

Litchfield Veterinary Hospital

289 Torrington Road
Litchfield, CT 06759

(860)567-1622

www.litchfieldvet.com

Mobile Patient Check In

     

In order to expedite our services and abide by specific protocols during the COVID-19 outbreak, please fill out the information below and click Submit The Form prior to your scheduled visit or upon arrival.  The information provided will be emailed to us, providing the doctor with pertinent information regarding your pet's visit.  

Thank you for choosing Litchfield Veterinary Hospital to serve you and your pet(s).

Patient Check In Form

Appointment :
Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Phone during appointment (required)
Phone TypePhone Number (required)
Make/Model/Color of your car: (required)

Reason for visit: (required)
Vaccines to perform
Annual Visit
Bloodwork
Problem/Concern
New pet exam
Other
Check all that apply:
Coughing
Sneezing
Vomiting
Diarrhea
Other
If your pet has any of the above symptoms or problems, please explain when it first occured, how often, and frequency:

Check what is normal:
Eating
Drinking
Urinating
Defecating
If not normal, please explain what is happening

For Cats:
Indoor
Outdoor
Diet
Current brand and amount fed per day:

For Canine Patients Only: Can your dog have peanut butter?
Yes
No
Medications
List all current medications and amount given per day:

Preventatives
Heartworm

Flea/Tick

Please list any refill requests for medications, diet, heartworm, or flea/tick prevention.

Additional Comments or Questions


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