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(928) 776-0932 | 2893 Venture Drive, Prescott AZ 86301

Home
About
Services
Rates & Fees
Reservations
- Request a Reservation
- Express Check-In Form
Forms
Quarterly specials
Education
Contact Us

Information & Evaluation

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Would you like to receive text reminders?*
- Yes
- No
Email*
Emergency Name*
First Last
Emergency Phone*
How did you hear about us?*
Client Referrals?
Other Website
Referral Hospital
Other
Pets name*
Species*
Date of Birth/age*
Breed*
Color*
Sex*
- Male
- Female
Neutered/Spayed?*
- Yes
- No
Current Veterinarian*
Please contact your veterinarian to have all records faxed over to us. Our fax: 928-776-0417
Current Veterinarian Phone Number
Patient Questionnaire
Does your pet have any specific handling needs?*
- Yes
- No
If Yes please explain:
Coughing*
- Yes
- No
If Yes, How long?
- Few days
- Few weeks
- Few months
Sneezing?*
- Yes
- No
Any eye discharge?*
- Yes
- No
If Yes, what color?*
- Yellow
- Green
- Clear
Any nose discharge?*
- Yes
- No
If Yes, what color?*
- Yellow
- Green
- Clear
Vomiting?*
- Yes
- No
How long?*
- Few days
- Few weeks
- Few months
Any undigested food/bile/foam or blood seen or red tint?*
- Yes
- No
Normal Bowel Movements?*
- Yes
- No
If Abnormal*
- Increased
- Decreased
Any Mucous/Blood?*
- Yes
- No
Urinating?*
- Normal
- Abnormal
If Abnormal*
- Increased
- Decreased
Any Blood/Straining?*
- Yes
- No
Water Intake?*
- Normal
- Abnormal
If Abnormal*
- Increased
- Decreased
Appetite?*
- Normal
- Increased
- Decreased
Brand Of Food:*
Amount:*
How Often:*
Limping?*
- Yes
- No
How long?*
- Few days
- Few weeks
- Few months
Which leg(s)?*
Any Recent Trauma?*
Lethargy?*
- Yes
- No
How long?*
- Few days
- Few weeks
- Few months
Itchy?*
- Yes
- No
How long?*
- Few days
- Few weeks
- Few months
Where is itching?*
Lumps?*
- Yes
- No
Where?*
Any history of seizures?*
- Yes
- No
When and how frequent?*
On Medications?*
- Yes
- No
Please list:*
Check Any Your Pet Is On*
- Heartgard
- Frontline
- Advantix
- Advantage
- Revolution
- Sentinel
- Bravecto
- Seresto
- Nexgard
- Other
- None
Do you have Pet Insurance?*
- Yes
- No
Who is the provider?*
Do you plan on boarding your pet at HCRS in the next 12 months?*
- Yes
- No
Can HCRS use your pet’s photo on our Facebook page?*
- Yes
- No
Dog Owners Only - Does Your Dog Frequent: Dog Parks/Doggie Daycare/Boarding/Grooming?
- Yes
- No
How often?*
Have you ever seen any of the following insects or rodents in your home?*
- Mosquitoes
- Mice
- Fleas
- Beetles
- Cockroaches
- Flies
- Other
- N/A
Do you have any other pets in your home?*
- Dog(s)
- Cat(s)
- Other(s)
- No other pets
Has traveled outside of the state?*
- Yes
- No
Where?*
Does your pet have any allergies we should be aware of*
- Yes
- No
If Yes please explain:
Additional Comments or Concerns:
Please provide a phone number for those text reminders:*
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Hassayampa Canine Resort & Spa
2893 Venture Drive, Prescott AZ 86301
Voice: (928) 776-0932
FAX: 928-852-2111
Email: appointments@hassayampacanine.com

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