E-Mail Address : Are you the owner of this animal? Yes No If no, please type your name Relationship to owner(s) Relative Friend Neighbor Other Has the owner of this animal or you been ill (with cough, fever, or shortness of breath) or diagnosed with COVID-19? (required) Yes No Pet Name Reason for Drop off If dropping off for a surgical procedure, did you fast your animal ANY KNOWN ALLERGIES TO VACCINES/MEDICATIONS Everything was okay with this pet until This pet is lethargic Water intake has Decreased Increased Unchanged Is this pet eating normally If No Eating More Eating Less Not eating at all For How Long
What food does this pet normally eat (include treats)?
Brand Wet Dry Grain Free Is it a new food If Yes, Since when Are human foods given If so what kind Is this pet vomiting Yes No If yes, this pet started vomiting on Is the vomit Water Foam Digested Food Undigested Food This pet last vomited Does this pet have normal stools If no Soft Diarrhea Watery Hard What color Is blood present
This pet has
Lost Weight Yes No Gained weight Yes No Is this pet Lame, Sore or has been injured I think his/her ____ are bothering him/her : None Eyes Ears Mouth Neck Stomach Back Legs Anal Area Skin This started It Has Worsened Improved Some This Has Recently Happened Is A Long Time (chronic) Problem Has this pet recently traveled outside your city If so, where? Has your pet recently been boarded Is this pet on any medications
Please list medications, dose and time
Medication How many tablets at a time Time of Day given Medication How many tablets at a time Time of Day given Please list any additional medications Please list any additional problems Is this pet currently on Heartworm prevention Flea/Tick control I am the owner/agent for described animal and authorize, and request an exam for this 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 my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges. If I cannot be reached at this number, I authorize initial diagnostics, including radiographs, and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid 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. 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 financial responsibility for charges incurred for this pet. Signature ( Please Type Name) (required) Todays Date