PFA Hillside Clinic
973-282-0890
401 Hillside Ave, Hillside NJ 07205
Visit us at www.pfaonline.org
Appointment Request Form and Preoperative Questionnaire
Your Information:
First Name: _______________________ Last name: _______________________ Pet name: __________
Street address _______________________ City_______________________ State ______ Zip_________
Home phone: _____________________ Cell phone: ______________________________
Email: __________________________________
Are you or anyone in your house positive for COVID-19 or have you or anyone in your house been exposed in
the last 14 days?_____
Alternative Contact first and last name: ______________________________________
Alternative Contact phone number: __________________________________________
Have you been to People for Animals in the last 6 years? ____________
Your Pet’s information: Please either circle/write out the answer. If you do not know – write
unsure.
Name _______________________________ Cat or Dog: _________ Breed: __________________
Color __________ Male or Female: _____________ Weight: _________________
Age (weeks, months or years): _________ Date of Birth (if known): __________________
Has your pet ever been to the vet before? _____________
What vet do you use regularly for your pet? __________________________________________
Please answer all questions. If you are unsure- write unsure, if no- write no, if doesn’t apply
then write n/a.
1. How long have you owned this pet? ___________
2. Where did you acquire this pet? ______________________________
3. When was your pet’s last vaccination? (enter Date, Never, or Unsure)
a. Rabies________________
b. Distemper (DAPP or FVRCP) _________________
c. Other ______________________
4. If your pet is male, are both testicles descended? (can you see both balls) (if you are unsure, write
unsure) ___________
5. If your pet is a female when was her last heat (menstrual) cycle? (You can answer Unsure or Never
if applicable) _____________________
6. If your pet is a female did she recently breed/mated? _______ Is she pregnant? (yes, no, possible)
___________
7. Does your pet have any medical condition, previous surgeries, injuries or illness? (if yes please list
all information)
_____________________________________________________________________________________________________
_______________________________________________________________________
8. Is your pet on any medication? (if yes, please list all medications and last date given)
______________________________________________________________________________
9. Does your pet have a history of seizures? _____________
10. Has your pet been hit by a car in the last three months? _____________
11. Has your pet ever bitten anyone? ____________
a. If yes, please explain and give the date________________________________________
Completed by: (your name) _____________________________________Date: ______________________
Appointment Request Form and Preoperative Questionnaire
12. Is your pet aggressive towards people? ___________
13. Is your pet aggressive towards other animals? _______________
Completed by: (your name) _____________________________________Date: ______________________
