Quick Fix Appointment Scheduling

1. Please provide your contact information:

Please provide your contact information: Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Daytime Phone Number:

Please provide the information requested below for the FIRST pet you wish to schedule; you will have the opportunity to add additional pets later in the questionnaire.

2. Please provide first pet's name:

Please provide first pet's name:

3. Please provide your pet's age:

Please provide your pet's age:

4. Species

Species Cat	Dog
Other (please specify)

5. Sex:

Sex: Male

Female

Not sure

6. Color(s):

Color(s):

7. How much does this pet weigh?

How much does this pet weigh?

8. If a CAT, describe breed type:

If a CAT, describe breed type: Domestic Long Hair Domestic Medium Hair	Domestic Short Hair Siamese type
Other (please specify)

9. If a DOG, describe breed type (beagle, lab, etc or just 'mix')

If a DOG, describe breed type (beagle, lab, etc or just 'mix')

10. Do you have a regular veterinarian?

Do you have a regular veterinarian? Yes	No	Not really
Name of regular veterinarian

11. When is the last time your pet visited a veterinarian?

When is the last time your pet visited a veterinarian? Within the last year 1-2 years ago	More than 2 years ago Never
Other (please specify)

12. Does this pet have a current rabies vaccination? (copy of certificate required, or $10 charge for vaccination at time of surgery).

Does this pet have a current rabies vaccination? (copy of certificate required, or $10 charge for vaccination at time of surgery). Yes

No

Other (please specify)

13. (Not Required)- The clinic also offers the following services. Please mark any that you would like to be done on surgery day.

(Not Required)- The clinic also offers the following services. Please mark any that you would like to be done on surgery day. $10 DA2PPv (distemper/parvo vaccine for dogs)

$10 Bordetella (kennel cough vaccine for dogs)

$15 Heartworm Test (dogs)

$20 Parasite package (dogs-worm/flea treatment)

$10 FVRCP (distemper/upper respiratory vaccine for cats)

$10 Feline Leukemia Vaccine

$20 Feline Leukemia/FIV combo test

$15 Parasite Package (cats-ear mites/worm/flea treatment)

14. Has this pet had any litters?

Has this pet had any litters? No

1

2

3 or more

15. If yes, what happened to those litters?

If yes, what happened to those litters? Sold Gave Away	Still have Took to a shelter
Other (please specify)

16. How many other pets do you have?

	0	1	2	3	4 or more
Dogs	How many other pets do you have? Dogs 0	1	2	3	4 or more
Cats	Cats 0	1	2	3	4 or more
Other	Other 0	1	2	3	4 or more

17. Are the other pets already spayed/neutered?

Are the other pets already spayed/neutered? Yes

Some are, some aren't

No

No other pets

18. Do you have another pet to schedule for surgery?

Do you have another pet to schedule for surgery? Yes

No

1. Quick Fix Appointment Scheduling