Medicating Consultation Questionnaire Medicating Consultation Form Owner Information First Name * Last Name * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Cell Phone * Alternate Phone * Email * Who referred you to us? * (Your vet, Google, friend, etc.) Pet Information Pet Name * Breed * Date of Birth * Age * Sex * Male Female Is your cat spayed/neutered? * Yes No Is your cat declawed? * Yes No Which paws? * Front paws All four How do you feed your cat? * (i.e. food out all the time, meals, timed feeder, via food puzzles, etc.) What brand(s) of food do you feed? * What type of food do you feed? * Canned Dry If you do not feed canned food, does your cat like it? * If you do not feed dry food, does your cat like it? * Does you cat like cat treats or any human foods? If yes, please list ALL of them! * Veterinarian Information Name of current vet practice * Name of veterinarian you see there * Clinic Phone Number * Clinic/doctor's email * Have you visited this veterinarian for this problem and have they prescribed the current medications that you are experiencing challenges administering? May we contact them for records? * Medical Information What medical conditions are currently being treated in your cat? * (i.e. kidney disease, hyperthyroidism, diabetes, a behavior problem requiring long-term anti-anxiety medications, etc.) What medication(s) were prescribed? * In what form? (check all that apply to what you have tried) * Pills Liquids Injections Transdermal Gel Compounded/medicated treats Powders Other Have you ever been successful medicating this cat? If yes, what worked? * What specific challenges are you having? * (i.e. can't catch cat, being bitten when pilling, meds tatse terrible and they are foaming at the mouth) Can you otherwise touch, handle and interact with your cat? * Does your cat hide from you? At meds time or all the time? * Can you pick your cat up? * Can you trim your cat's nails? * Anything else you wish to share that would help us, help you? Legal Stuff By submitting this questionnaire, I understand that the recommendations given by Fundamentally Feline are in no way a substitute for veterinary care. I understand that the success depends upon my compliance and ability to follow through with the skills learned to become proficient. In some rare cases, some cats cannot be medicated without it affecting the pet/parent relationship and without affecting quality of life. I release Fundamentally Feline from any and all liability in regard to health and behavior of my pets, the safety of all people in the household who interact with the cat, damage or loss to my property and in regard to any aspect of the advice given. I understand that payment is due in full at the time of service. If you are human, leave this field blank. Submit Form
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