Dog New Patient Information Packet and Questionnaire

Florida Veterinary Behavior Service Dog Behavior Intake Questionnaire
Lisa Radosta DVM, DACVB
Hello!
Thank you for making a behavioral medicine appointment for your pet. We have been providing specialty behaviorial medicine treatment to our patients in south Florida since 2007. Our team is committed to helping your pet overcome his or her behavior disorders.

In this packet, you will find the following items:

1. A registration form

2. Tips for your pet's appointment

3. A patient questionnaire

These forms will automatically submit to us when you submit online.

Please let us know what we can do to help you in the time leading up to your pet's appointment. You can find maps with our location information and direct numbers to those hospitals at our website:www.flvetbehavior.com.

We are looking forward to meeting you and your pet!

Sincerely,

The Florida Veterinary Behavior Service team
Your Information and Legal Stuff
Primary Pet Parent (your pet's medical record will be under this person)
Full Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Pet Parent
Full Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I am the owner(s) of the animal(s) seeking behavioral medicine treatment from the Florida Veterinary Behavior Service. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggression is unpredictable and will remain unpredictable after its treatment. Florida Veterinary Behavior Service cannot promise that the animal's Behavior Service treatment, training or advice will eliminate the animal's potential danger to persons or completely control the animal's aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinances and "leash laws."I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my petTelehealth appointments may be recorded for internal training only.*

I understand
We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use for images of your pet. When used, there will not no identifying information of the pet or yourself such as your name. Please consent below to whichever option works best for you.

My pet's pictures and videos are to be used only for my pet's medical record.My pet's pictures and videos can be used for my pet's medical record, textbooks, veterinary publications including journals, textbooks and electronic publications, veterinary presentations.Do not use my pet's picture for any purpose including in his or her medical records.
If at least one pet parent listed above will not be physically present at your pet's appointment, please list below the person(s) with whom we are authorized to speak. We cannot speak with anyone about your pet's care outside of the pet parents listed above and your pet's primary care veterinarian without written authorization.
FVBS utilizes ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:1. Appointment Recording: You agree that your pet's appointments may be recorded. 2. UsageRights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation.3. Age Confirmation and Understanding: You affirm that you are at least eighteen years old and that you understand and accept the terms of this agreement.*

I understand
Primary Pet Parent's Signature (use your cursor to sign)*
SecondaryPet Parent's Signature (use your cursor to sign)

Your Pet's Information
Who referred you to the Florida Veterinary Behavior Service?
Who is your pet's primary care veterinarian? Please list the veterinarian, clinic name and phone.
Please list additional veterinary hospitals where your pet has been seen in the past 5 years.
Pet Name
Breed
Date of Birth or Age
Sex

MaleFemale
Neutered/Spayed

YesNo
Age at which your pet was neutered or spayed
Where did you get your dog?
How long have you had your dog?
Has your dog had other owners?

YesNo
If so, please tell us more about your pet's adoption history.

0/50
What are your goals for this appointment?

0/100

Sleep Behaviors
Does your pet sleep through the night?

YesNo
Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

YesNo
Does your pet take naps during the day when you are home?

YesNo

Anxiety/Distress in the car

If your dog exhibits anxiety or distress when riding in the car please fill out this section. If not, go to the next section.
Please check all that apply to your dog's behavior when riding in the car

Calm and relaxedDroolingPacesPantsVomitsBarks, whines or cries at youTries to climb on top of youDefecates
Please add any additional information that you would like to share about your dog's behavior in the car.

Cancellation Policy
We strive to provide excellent behavioral medical care to all of our patients. New patients often wait 3-4 months to see one of our doctors. When appointments are cancelled without adequate notice, it prevents other patients from receiving care. For that reason, please give us one business day's notice when cancelling or rescheduling an appointment.
If you are 10 minutes or more late for your appointment, it will be automatically rescheduled.*
$150 prepayment will be forfeited if assessment appointments are cancelled or rescheduled with less than two business day's notice.*
$45 fee applied to your account if appointments are cancelled or rescheduled with less than one business day's notice.*
$65 fee applied to your account if no notice (no show) for a missed appointment.*
A second no notice (no show), you will be required to submit full payment when the appointment is scheduled. This fee is non-refundable.*

Have pictures or videos to upload?

Upload videos and pictures directly to our DropBox by clicking here.

When using the Dropbox link above, you will be brought to our Dropbox page and away from this site in a new window. Your questionnaire form will not be submitted if you do not navigate back to this page and click submit.

You can also email photos/videos to info@flvetbehavior.com.
When you have completed the entire questionaire form, click submit.
Should be Empty:

	Daily	Weekly	Monthly	Several times a year	Never
Vomiting
Diarrhea
Constipation
Decreased appetite
Excessive licking
Lip licking

	0	1	2	3
Gets stuck, difficulty getting around objects, goes to hinge side of door
Stares blankly at walls, floor, or into space
Does not recognize familiar people/familiar pets
Gets lost in home or yard
Less reactive to visual (sights) or auditory (sounds) stimuli
More irritable/fearful/aggressive with visitors, family, or other animals
Decreased interest in approaching, greeting or affection/petting
Pacing/restless/sleeps less/waking at night
Vocalization at night
Less able to learn new tasks or respond to previously learned commands/name/work
Indoor soiling of urine or stool/decreased signaling to go out
Difficulty getting dog's attention/increased distraction/decreased focus
Decrease in exploration or play with toys, family members, other pets
Increased activity including aimless pacing or wandering
Repetitive behaviors (e.g. circling, chewing, licking, star gazing)
Increased anxiety when separated from owners
More reactive/fearful to visual (sight) or auditory (sounds) stimuli
Increased fear of places/locations (e.g. new environments or going outdoors)

Florida Veterinary Behavior Service Dog Behavior Intake Questionnaire

Your Information and Legal Stuff

Your Pet's Information

Cancellation Policy

Cognitive Dysfunction Screen