Thorpe Animal Hospital

1678 Mayfield Rd
Lapeer, MI 48446

(810)664-2233

www.thorpevet.com

COVID-19 APPOINTMENT FORM

To help protect our clients and employees from exposure to the COVID-19 virus, we are taking appointments for sick/injured pets only at this time. Those existing patients that require vaccines or other services may be scheduled at the doctor's discretion. Our hospital asks that you fill out this form in order to better facilitate the examination of your pet in your absence. Thank you for your patience as we figure out how to provide your pet with necessary care while preventing the spread of COVID-19 in our community. 

PRINTABLE COVID-19 APPOINTMENT FORM

COVID-19 Appointment Form

Client Name First/Last
First Name
Last Name
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 :
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.
Phone
Phone TypePhone Number
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 :

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