Tender Touch Veterinary Hospital

151 Wexford-Bayne Road (Rt. 910)

Wexford, PA 15090

Contact Us:

Phone: 724-933-7387

Fax: 724-933-7383

Email: ttvh151@gmail.com

Client/Patient Information

Owner Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Co-Owner Name (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How long has your pet been in your home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Appointment Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Appointment Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Eating/Drinking Habits

What type of food(s) does your pet eat? (Select all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

What brand(s) do you feed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please rate your pet's eating or drinking habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

	Much Less	Less	No Change	More	Much More
{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

How long ago did you notice a change in your pet's appetite? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How long ago did you notice a change in your pet's water intake? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Have you noticed your pet dropping food or treats from his/her mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you noticed any drooling or foul odor from your pet's mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

How often does your pet vomit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Urination/Defecation

Is your pet having accidents in the house/outside the litterbox? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

How often? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please describe your pet's urination habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

	Much Less	Less	No Change	More	Much More
{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

{{ $context.parentContext.dataItem.get_label() }}	{ binding displayValue, mode=oneTime }

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How often does your pet have diarrhea? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mobility & Pain

Have you noticed any falls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does your pet have trouble climbing stairs/onto furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you noticed any stiffness or limping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet still interested in going for walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does he/she still play with toys? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does your pet have trouble going coming down the stairs or getting off furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does your pet have trouble positioning for urination or bowel movements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Behavior

Have you found your pet hiding in new places? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Is your pet staring into space or staring at walls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you noticed any new nighttime habits/sleep disturbances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet walking the walls (leaning on walls or furniture) as he/she walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Sensory

Does your pet respond when you call his/her name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Does he/she still react to stimuli (e.g. doorbell, mailman, sound of treat bag crinkling)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Have you noticed your pet walking into walls or furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Current Medications & Treatments

Please list your pet's current medications/supplements. Add more by clicking the "Add Medication/Supplement" at the bottom of the section.

Medication/Supplement {binding ItemNumber}

Medication/Supplement Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Drug Strength (e.g. 50mg) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Dose on Label (e.g. 1 tablet by mouth every 12 hrs) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

How often does your pet receive this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you need a refill? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you have any questions about this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Enter your question(s) here for the veterinarian to address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Owner-specific Concerns

Please add any additional questions or concerns you would like to discuss at your pet's appointment: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Tender Touch Veterinary Hospital

151 Wexford-Bayne Road (Rt. 910)

Wexford, PA 15090

Contact Us:

Phone: 724-933-7387

Fax: 724-933-7383

Email: ttvh151@gmail.com

Client/Patient Information

Owner Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co-Owner Name (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pet Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long has your pet been in your home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Appointment Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Appointment Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Eating/Drinking Habits

What type of food(s) does your pet eat? (Select all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What brand(s) do you feed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please rate your pet's eating or drinking habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice a change in your pet's appetite? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice a change in your pet's water intake? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed your pet dropping food or treats from his/her mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any drooling or foul odor from your pet's mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet vomit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Urination/Defecation

Is your pet having accidents in the house/outside the litterbox? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please describe your pet's urination habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet have diarrhea? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mobility & Pain

Have you noticed any falls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does your pet have trouble climbing stairs/onto furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any stiffness or limping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet still interested in going for walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she still play with toys? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your pet have trouble going coming down the stairs or getting off furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your pet have trouble positioning for urination or bowel movements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Behavior

Have you found your pet hiding in new places? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is your pet staring into space or staring at walls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any new nighttime habits/sleep disturbances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet walking the walls (leaning on walls or furniture) as he/she walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Sensory

Does your pet respond when you call his/her name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she still react to stimuli (e.g. doorbell, mailman, sound of treat bag crinkling)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed your pet walking into walls or furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Current Medications & Treatments

Medication/Supplement {binding ItemNumber}

Medication/Supplement Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Drug Strength (e.g. 50mg) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dose on Label (e.g. 1 tablet by mouth every 12 hrs) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet receive this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you need a refill? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any questions about this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Enter your question(s) here for the veterinarian to address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Owner-specific Concerns

Please add any additional questions or concerns you would like to discuss at your pet's appointment: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Tender Touch Veterinary Hospital

151 Wexford-Bayne Road (Rt. 910)

Wexford, PA 15090

Contact Us:

Phone: 724-933-7387

Fax: 724-933-7383

Email: ttvh151@gmail.com

Client/Patient Information

Owner Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co-Owner Name (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pet Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long has your pet been in your home? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Appointment Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Appointment Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Eating/Drinking Habits

What type of food(s) does your pet eat? (Select all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What brand(s) do you feed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please rate your pet's eating or drinking habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice a change in your pet's appetite? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice a change in your pet's water intake? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed your pet dropping food or treats from his/her mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any drooling or foul odor from your pet's mouth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet vomit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Urination/Defecation

Is your pet having accidents in the house/outside the litterbox? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please describe your pet's urination habits: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long ago did you notice this change? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet have diarrhea? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mobility & Pain

Have you noticed any falls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does your pet have trouble climbing stairs/onto furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any stiffness or limping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet still interested in going for walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she still play with toys? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your pet have trouble going coming down the stairs or getting off furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your pet have trouble positioning for urination or bowel movements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Behavior

Have you found your pet hiding in new places? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is your pet staring into space or staring at walls? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed any new nighttime habits/sleep disturbances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Is your pet walking the walls (leaning on walls or furniture) as he/she walks? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Sensory

Does your pet respond when you call his/her name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does he/she still react to stimuli (e.g. doorbell, mailman, sound of treat bag crinkling)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you noticed your pet walking into walls or furniture? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Current Medications & Treatments

Medication/Supplement {binding ItemNumber}

Medication/Supplement Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Drug Strength (e.g. 50mg) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dose on Label (e.g. 1 tablet by mouth every 12 hrs) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often does your pet receive this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you need a refill? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any questions about this medication/supplement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Enter your question(s) here for the veterinarian to address: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Owner-specific Concerns

Please add any additional questions or concerns you would like to discuss at your pet's appointment: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }