Cat Behavior Intake Form

Owner Name(Required)
Address(Required)

BEHAVIOR VIDEO —

Please take a 2 minute or less video of the behavior(s) when you think it will be helpful. Once you have your video, please send the video via text message to (631) 923-2530. Please include your name and your cat’s name on the video submission.

IMAGE AND VIDEO CONSENT —

We may take pictures and videos as a part of your pet’s appointment. Below is a consent questionnaire for our use of images of your pet. When used, there will be no identifying information of your pet or you, such as your name. Please consent below to whichever options works best for you.
Image and Video Consent Choice(Required)

CAT BEHAVIORAL QUESTIONNAIRE —

PLEASE MARK ALL OF THE APPROPRIATE BOXES AND FILL IN THE BLANKS TO THE BEST OF YOUR ABILITY
Has your cat had any other owners?(Required)
Tell us about your pet's environment. Check all that apply.(Required)
Do you have multiple pets?(Required)

HEALTH, WELLNESS, AND WELFARE

What is your cat's activity level in general?(Required)
Does your cat take naps during the day when you are home?(Required)
Does your cat sleep through the night?(Required)
Have you noticed any change in your cat's sleeping patterns in the past 3 months?(Required)
Does your cat experience any of the following?(Required)

BEHAVIOR PROBLEM INFORMATION

Please fill out the section below regarding your three top concerns about your pet’s behavior.
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At what age did problem #1 start?(Required)
Frequency of problem #1(Required)
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At what age did problem #2 start?
Frequency of problem #2
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At what age did problem #3 start?
Frequency of problem #3
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ELIMINATION BEHAVIORS

Does your cat ever eliminate outside the litter box, in the house?(Required)
When your cat uses the litter box, does he or she…? Check all that apply.(Required)

LITTER BOX INFORMATION

Is litter box #1 covered or uncovered?(Required)
Does litter box #1 have a liner?(Required)
Is litter box #2 covered or uncovered?
Does litter box #2 have a liner?
Is litter box #3 covered or uncovered?
Does litter box #3 have a liner?
How often are the litter boxes scooped?(Required)
What previous treatments have been tried? Check all that apply.

AGGRESSIVE BEHAVIOR

Does your cat exhibit aggressive behaviors (biting, scratching)?(Required)
What does your cat do when separated from the family? Check all that apply.(Required)
What does your cat do when visitors enter the home? Check all that apply.(Required)

EUTHANASIA / REHOMING

Did someone recommend euthanasia before your visit to us?(Required)
Have you considered euthanasia before this visit?(Required)
Have you considered re-homing you cat before your visit?(Required)
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AUTHORIZATION

I am the owner of the animal seeking behavioral medicine treatment from Gold Coast Center for Veterinary Care. 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. Gold Coast Center for Veterinary Care cannot promise that the animal’s behavior service treatment, training or advice will completely eliminate the animals potential danger to persons or completely control the animal’s aggressiveness.

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 pet.

Telehealth appointments may be recorded for internal training only.
This field is for validation purposes and should be left unchanged.