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(847) 459-7535
2051 Waukegan Road, Bannockburn, IL 60015

Home
Who We Are
Pet Owners
Specialties
Veterinary Professionals
Contact
- Appointment Request
Blog

Appointment Request

Refer a Patient

(847) 459-7535 / 2051 Waukegan Road, Bannockburn, IL 60015

24 Hour Emergency & Critical Care

Current Wait Time for ER: Minutes

Please call us before coming in to discuss your pet's current condition.

Get in Line for the ER

Synovetin OA® Screening Questionnaire

Owner Name(Required)

First Last

Pet Name(Required)

First

Person Interviewed(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Household members:

Gender

Age

Describe each household member’s interaction(s) with your dog as direct, close and intermediate activities. Direct activities are <1ft (e.g., carrying the dog where the elbow is in contact or lap sitting where the elbow is directly on the torso). Close activities are at 1ft (e.g., feeding, grooming, sleeping, and routine lap-sitting) Intermediate activities are at 3ft (e.g., walking, jogging, and officing).

Household Member 1:(Required)

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 2:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 3:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 4:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Answer the questions below. Any No* checkmark may be contraindicated for the procedure. Contraindication is based on caretaker responses, proposed dose to pet, or other clinical factors.

Can interactions with children and pregnant women be modified to minimize close contact with the dog?(Required)

Yes

N/A

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If the answer to the above question is yes, describe proposed modifications:

Does your dog currently sleep in the same bed with any household members?(Required)

Yes

N/A

Since you answered YES above, can arrangements be made to avoid this for the duration indicated on the Release Instructions?(Required)

Yes

N/A

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If the answer to the above question is yes, describe proposed modifications:

Is your pet mobile enough to climb stairs and/or enter and exit a vehicle independently?(Required)

Yes

N/A

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If the answer to the above question is no, provide the owner with additional strategies:

Does your dog jump up to beds or furniture with family members, or lap sit?(Required)

Yes

N/A

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If yes, can arrangements be made to avoid this for the duration indicated on the Release Instructions (i.e., not lap sit)? Describe proposed modifications:

Does your dog currently sit in very close proximity (i.e., next to your chair or at your feet) to you for more than 3 hours per day?(Required)

Yes

N/A

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If yes, can arrangements be made to avoid this for the indicated time frames on the Release Instructions? Describe proposed modifications:

This field is hidden when viewing the form

Has the owner been provided with an example Release Instructions sheet?

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Does the owner fully understand the procedure they have arranged for their pet?

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Are the household members able and willing to modify your routine interaction with your pet for the time frames indicated on the Release Instructions?

This field is hidden when viewing the form

If the answer to the above question is yes, describe proposed modifications: