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Home
About Us
Services
Resources
- FAQs
- Forms
- Payment Options
- Blog
- Careers
Contact
Book Appointment

Please note our winter closures:
December 24, 2024 – December 26, 2024
December 31, 2024 – January 1, 2025

Senior Dog Wellness Questionnaire

Please complete the online form below prior to your visit at
West Ballantyne Animal Hospital.

Get Started

Senior Dog Wellness Questionnaire

Please complete the form below as thoroughly as possible.

- Step 1 of 3

Name *

First

Last

Phone *

Email *

Pet's Name *

What specific concerns would you like to address with the veterinarian about your pet? Please be specific with details of severity and duration. *

What medication is your pet currently taking? When was the last dose? Do you need refills? *

What preventions are your pet on? When was the last dose? Do you need refills? *

What supplements or over the counter medications does your pet take? *

Is your pet coughing/sneezing/vomiting or having diarrhea? *

What diet do you feed your pet and how much/how often? *

Brand Name of Food/Protein Source *

Grain Free? *

Yes
No

Amount of Food *

How would you describe your pets life style: *

Mostly indoors and rarely outdoors
Mostly indoors and a few hours outside daily
Mostly indoors but also enjoys the outdoors with adventures
Strictly outdoors

How often does your pet visit dog parks, grooming facilities, boarding facilities, or breweries? *

Weekly
Monthly
Quarterly
Rarely
Never

Have you or anyone in your household experienced flu-like symptoms recently? *

Yes
No

Have you noticed any of the following changes?

Changes in appetite *

No changes
Eating more
Eating less

Changes in drinking *

No changes
Drinking more
Drinking less

Changes in urination *

No changes
Increased amount
Decreased amount

Changes in coat (please explain)

Changes in your pet's activity level *

Same/No changes
Less active
More active

Changes in breathing or breathing patterns *

No changes
Coughing
Sneezing
Difficulty breathing

Have you noticed new lumps or bumps on your pet's skin? If yes where? *

Have you noticed any changes in your pet's mobility? If yes, please explain *

Please list all the medicine and supplements you pets is currently taking

Upload a photo of your pet (optional)

Click or drag a file to this area to upload.

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Location

11926 Providence Rd W Suite E0
Charlotte, NC 28277

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Hours

Mon - Fri: 7:30 AM - 6:00 PM
Sat: CLOSED
Sun: CLOSED

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Contact

Phone: 980-938-8136
Email: wbah@westbah.com

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For Emergencies Contact

Carolina Veterinary Specialists

Charlotte: 704-504-9608
2225 Township Rd
Charlotte, NC 28273

Matthews: 704-815-3939
4099 Campus Ridge Rd
Matthews, NC 28104

Drop us a line!

Have a question? Use the form below, and we'll get back to you as quickly as possible. If you need immediate assistance, please call us directly at 980-938-8136.

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

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