Owner's Name
Pet's Name
Date
MM slash DD slash YYYY
Address, Phone or Email Changes?
Yes
No
Changes are...
My pet is being dropped off for the following reason/treatment:
Duration of the problem?
Location of the problem?
Is your pet on any medications?
Yes
No
If yes, name and dosage
Last given
Did your pet eat this morning?
Yes
No
Was food offered?
Yes
No
Has your pet had any reaction to medications?
Yes
No
Has your pet had any reaction to vaccines?
Yes
No
Have you administered flea or heatworm prevention in the past 3 weeks? If so what kind?
Yes
No
If so, what kind?
HISTORY (mark any that apply)
Has your pet shown any signs of the following?
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Vomiting?
How long?
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Diarrhea?
How long?
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Lethargic?
How long?
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No appetite?
How long?
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Weakness?
How long?
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Coughing?
How long?
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Gagging?
How long?
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Scratching?
How long?
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Hair loss?
How long?
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Straining to urinate?
How long?
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Lumps?
How long?
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Shaking head?
How long?
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Scooting?
How long?
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Seizures?
How long?
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Urinating more or less than usual
How long?
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Drinking more or less than usual?
How long?
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Limping?
Which leg?
How long?
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Weight loss or weight gain?
How long?
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Bad breath?
How long?
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Straining to defacate?
How long?
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Panting?
How long?
Consent
In the event of an emergency or if further diagnostics should be needed, we will make our best effort to reach you at the number provided below. However, should we be unable to reach you, pleas choose one of the following options:
Consent
I DO authorize additional treatment.
I DO NOT authorize additional treatment of ANY kind without my consent, with the exception of life-saving treatments.