Mazomanie Animal Hospital

704 Emily Rd
Mazomanie, WI 53560


Sick Pet Check In Form

Thank you for scheduling an appointment with your pet! 

Please fill out the form below to help us best serve you and your pet during their visit.

Thank you for your time!

Sick Pet Check In Form Form

Email (This should be the main email you would like us to use for your account)

Pet's Name

Owner's Name (That account is under in our system)

Who will be bringing your pet to their appointment?

What is the best contact number for that person during the appointment time?

Street Address
State / Province
Zip / Postal Code
Phone TypePhone Number
Is this a cell phone that can accept text message reminders from us?


Please help us by filling out the following information.
Please write no or yes. If the answer is yes, please describe. If the question does not apply to the reason for your pet's visit, please leave blank.
Please describe the reason for your pet's visit?

Has your pet been acting lethargic or having any unusual behavior such as hiding? If yes, please describe.

How long has it been since your pet hasn't been feeling well (In days)?

Has your pet had any vomiting? If yes, please describe frequency.

Has your pet had any diarrhea? If yes, please describe frequency and consistency.

Has your pet had a decreased appetite? If yes, please describe what you have tried feeding them and what they will eat.

Has your pet had an increase or decrease in water intake? If yes, please describe their current water intake.

Has your pet had an increase in urination frequency or amount? If yes, please describe.

Does your pet have a history of a similar problem? If yes, please provide a brief description and approximately when it occured?

Do you have any other questions or concerns?

Do you need any preventative medications or medication refills sent home with your pet? If yes, please describe.

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