Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-5640

www.adsuny.com

Drop Off Questionnaire

Pet's Name, Your Last Name (required)
First Name (required)
Last Name (required)
Activity level normal? (required)

yes
no


Eating and drinking normally? (required)

yes
no


Did he/she eat today? (required)

yes
no


If so, what time?

What brand of food has he/she been eating at home? (required)

How much food is he/she eating? (required)

Does he/she receive any treats? (required)

yes
no


If so, what kind?

Any vomiting? (required)

yes
no


If so, how often? Duration? How long after eating? What does the vomit look like?

Any diarrhea or constipation? (required)

yes
no


If so, how often? Duration? Appearance of stool (if abnormal)? Is there blood in it?

Any coughing? (required)

yes
no


If so, how many times per day? Duration? Cough anything up?

Any sneezing? (required)

yes
no


Any changes in mobility? (required)

yes
no


If so, please describe.

Urinating normally? (required)

yes
no


If not, what is abnormal? Any accidents in the house?

Any scratching? (required)

yes
no


If so, on a scale of 1-10 with 10 being unbearably itchy, how itchy?

1
2
3
4
5
6
7
8
9
10


Any fur loss noted? (required)

yes
no


What medications is he or she receiving and how often? (required)

Were any given this morning? If so, which ones and at what times? (required)

Is your pet receiving heartworm preventative? (required)

yes
no


If so, what kind?

Is your pet receiving flea and/or tick preventative? (required)

yes/no


If so, what kind?

Any other concerns we should know about?


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HOURS


Day Open Close
Monday *7:00am 6:00pm
Tuesday *7:00am 6:00pm
Wednesday *7:00am 6:00pm
Thursday *7:00am 6:00pm
Friday 7:00am 2:00pm
Saturday Closed Closed
Sunday Closed Closed

*Scheduled surgical procedure days.


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Contact

Phone:  315-445-5640

Email:  contact@adsuny.com


Fear Free Certified Professionals