Owners Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Pet's Name
*
What time would you prefer to pick up?
*
Reason for Visit
*
Please Check all That Apply
Energy Level
*
Normal
Increased
Decreased
Appetite
*
Normal
Increased
Decreased
Weight
*
Loss
Gain
Stable
Water Consumption
*
Normal
Increased
Decreased
Bowel Movements
*
Soft
Normal
Constipated
Diarrhea
What is the Appearance?
*
Excessive Hair Loss
*
Patchy
Generalized
Where?
*
Urination
*
Normal
Increased
Decreased
Discolored Urine
Incontinence
Straining
What color?
*
SYMPTOMS (Please Check All That Apply)
Difficulty Rising
*
After Sleeping
After Exercising
Climbing Stairs
Stiffness
Scooting on Rear
Shaking Head
Bad Breath
Vomiting
Coughing
Sneezing
Gagging
Listless
Signs of Weakness
Lameness
Scratching
Lumps or Bumbs
Discharge
Behavioral Changes
Additional Comments
*
When did you first notice this issue?
*
Have you given your pet any medications today (List)?
*
When was the last time your pet ate or drank anything?
*
**There Will Be An Additional Charge For Sedation, Bloodwork, XRays, And Any Other Test Or Treatment Performed**
By checking this box i agree that i am the owner/agent for described animal, authorize, and request an exam for my pet. I understand that sedation and/or pain medication will be provided if deemed reasonable. I understand the doctor will contact me after she has examined by my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges. I can be reached at the provided number on this form. If I cannot be reached at this number, I authorize initial diagnostics, incluiding xrays and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and support and other supportive medications be started as indicated for my pet. I authorize anesthesia, surgery and medications if needed for abscess, laceration or other wounds, if my pet is presented for one of these problems (please fill out additional consent forms). I understand, and accept that when anesthesia is involved, there are always inherent risks, including death. I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept full financial responsibility of charges incurred for this pet. I understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.
*
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