Appointment Questionnaire

MANDATORY CHECKLIST FOR APPOINTMENT: The below questions must be answered prior to your appointment

Name
First Last
Pet Name
Consent*
I certify all of the below statements to be TRUE

I have not been in contact with anyone that has been diagnosed with Covid-19 in the past 14 days

Neither myself nor anyone else in my household have any symptoms of Covid-19 including sore throat, shortness of breath, coughing or fever.

Neither myself nor anyone else in my household have been travelling outside of Canada in the last 14 days.
Consent*
I have a cellphone (or am located at a landline) where the doctor can call during the appointment to talk about my pet.
Phone*
Consent*
I understand that video conferencing is available during my visit. I will need to have ZOOM downloaded on my phone prior to the appointment (it is not necessary to set up an account). See more detailed instructions at the end of this form.
If you would like to have the zoom video conference link emailed to you, please provide an email address below:
Consent*
I understand that as per our current Covid-19 policies I will not be allowed to accompany my pet into the hospital (excluding euthanasias).
Consent*
I have a Visa, Visa Debit or MasterCard to pay with over the phone at the time of the appointment.
Consent*
I understand that I must have my pet on a securely tightened collar/harness and leash (not extendable leashes if possible please) or in a secure carrier.
Consent*
I will inform the staff if my pet has special needs. It is helpful for us to know if your pet is aggressive with other pets or humans. If your pet is fearful or anxious, we may be able to provide some anxiety medications in advance for you to give 1-2 hours before the appointment.
Consent*
I understand that it is recommended for me to bring a fresh stool sample in case it is needed.
Consent*
I understand that it is recommended for me to bring a fresh urine sample if my pet has any increased drinking, change in urination habits
What diet is your pet being fed (Brand, Type, flavour)?:
How much pet food does your pet get per day exactly (# cups)?:
Please list as precisely as possible all other treats, chews, table food that your pet gets in a day including amounts:
Please list any medications or supplements that your pet is taking (including strength, and frequency):
Has your pet been to another facility from which we should request records to complete his/her file?:
Does your pet travel outside of Kitchener (i.e. cottage)? If YES, where?:
Does your pet spend time outdoors, please describe where:
How much exercise does your pet get?
Has your pet had any vomiting? If YES, please describe (frequency, appearance etc):
Has your pet had any diarrhea? If YES, please describe (frequency, appearance etc):
Has your pet had coughing or sneezing or difficulty breathing?
Does your pet have any mobility concerns (difficulty with stairs, getting onto bed, getting into car)?:
Does your pet have any lumps/bumps that you would like the doctor to assess? If YES, please list their locations, size and how long they have been present.
Please list any other health concerns you have with your pet
Please don’t hesitate to call if you have any questions or concerns prior to your appointment. If you are unable to make your appointment, please give us 24 hours notice to cancel or reschedule so that we can accommodate another patient in your place.
IF YOU WOULD LIKE A VIDEO CONFERENCE:
● Download ZOOM on your desktop, phone or laptop from wherever you purchase your apps.
○ You do not need to create your own account
○ Please ensure you have the app downloaded on your phone, tablet or laptop well aheadof your appointment time, and you are clear on how to use it.
○ You will be emailed a meeting code that you can click on at your scheduled appointment time. This should open the meeting up in your ZOOM app automatically.
○ Alternatively, you can open the ZOOM app and choose “join a meeting” and enter in the meeting ID code manually
○ Ensure that you allow video conferencing
○ Ensure that MUTE is not clicked at the bottom of the screen.
○ If you are not able to connect, please call the clinic immediately

Have a Question? Need to book an appointment?

Name: Gateway Pet Hospital
Address: 4391 King St E, Kitchener, ON, N2P 2G1, CA
Telephone: (519) 653-1003

Connect with us and one of our team members will be happy to assist you.

Contact Us

4391 King St E
Kitchener, ON N2P 2G1

Ph: (519) 653-1003
Fx: (519) 653-1320

[email protected]

Hours of Operation

(COVID-19 hours) – normally open Mon-Fri (8-7) Sat/Sun (9-4)

Mon 8 am – 6 pm
Tue 8 am – 6 pm
Wed 8 am – 6 pm
Thur 8 am – 6 pm
Fri 8 am – 6 pm
Sat 9 am – 4 pm (Vet available 9 – 3)
Sun – closed

EMERGENCY HOURS

For all after-hours emergencies please call (519) 650-1617

Pet Emergency Make An Appointment