Client InformationClient Name* First Last Client Phone*Client Email Patient InformationPet's Name* Breed* Age* Sex*MaleMale NeuteredFemaleFemale SpayedReason for Visit* Has your pet experienced these symptoms previously?* Yes No When was the last episode?*Did the symptoms resolve with treatment?* Yes No Is your pet current on heartworm preventatives?* Yes No Type* Injectable Oral Frequency:* Every 6 Months Every 12 Months Frequency:* Monthly Seasonally Is your pet current on flea and tick preventatives?* Yes No Type* Topical Oral Frequency:* Monthly Seasonally Is your pet currently taking any medications or supplements?* Yes No Please List:*Dietary HabitsWhat brand of food is your pet currently on?* What type of food does your pet eat?* Canned Dry Does your pet regularly receive treats?* Yes No People food or table scraps?* Yes No Please Explain:*Pet Treats? Yes No Please Explain:*Have there been any recent changes to your pet’s dietary habits?* Yes No Please Explain:*Has your pet eaten today?* Yes No How much?* Ate Well Ate Half Ate a little Are there any changes in your pet’s water consumption?* Yes No Increased or Decreased?* Increased Decreased Severity?* Mild Drastically Please select any of the following options which describe any problems your pet is currently exhibiting. Vomiting Diarrhea Changes in urinary habits Respiratory Issues Lameness or Possible Injury When did the vomiting begin?*How often is your pet vomiting?*Did you observe a vomiting episode?*When was the last time your pet vomited?*Please make notes regarding appearance.*When did the diarrhea begin?*Please make notes regarding the appearance.*How often is your pet having to go?*Is your pet having accidents?* Yes No Please Explain*Are there changes in the frequency of urination?* Yes No Increased or Decreased?* Increased Decreased How often is your pet going?*Are there changes in the amount of urine produced?* Yes No Increased or Decreased?* Increased Decreased Please Explain*When did these issues begin?*Sneezing or discharge from the nose or eyes?* Yes No When did the sneezing start or the discharge appear?*How often have you notice the sneezing?*Please describe any discharge present.*Coughing or gagging?* Yes No When did the coughing start?*How often have you noticed coughing?*Is anything produced with your pet does this?* Yes No Please Explain*Lame (non-weight bearing)?* Yes No Front or Rear?* Front Rear Left or Right?* Left Right When did this begin?*Did you see any injury to the limb?* Yes No Please Explain:*Have there been any changes to the area/limb since this began?* Yes No What type of changes? Swelling Changes in natural placement Other Please Explain*Does your pet have a history of similar injuries?* Yes No Please Explain*When was the last time your pet had a similar episode?*Have you given any medications to help with pain or inflammation?* Yes No What medication was given?*How Much?*When was the last dose?*Limping?* Yes No Front or Rear?* Front Rear Right or Left?* Right Left Do you see any injury to the limb?* Yes No Please Explain*When did this begin?*Has the condition changed since you noticed your pet limping?* Yes No How So?* Worsened Remained the same Improved some Does your pet have a history of similar injuries?* Yes No Please Explain:*When was the last time your pet had a similar episode?*Have you given any medications to help with pain or inflammation?* Yes No What medication was given?*How Much?*When was the last dose?*Sore or Tender?* Yes No Where does your pet appear tender or sore?* Limb or Paw Back or Neck Other area Front or Rear?* Front Rear Right or Left?* Right Left Please Explain*When did this begin?*Has the condition changed?* Yes No How So?* Worsened Remained the same Improved some Does your pet have a history of similar injuries?* Yes No Please Explain:*When was the last time your pet had a similar episode?*Have you given any medications to help with pain or inflammation?* Yes No What medication was given?*How Much?*When was the last dose?*Lumps, bumps, or masses?* Yes No When did you first notice the lump?*Have you noticed any changes in the size of the lump?* Yes No Increase or Decrease?* Increase Decrease Have you noticed any changes in the consistency of the lump?* Yes No How So? Harder Softer No longer mobile If deemed medically necessary by the attending veterinarian, I authorize the any necessary imaging, blood work or labs including, but not limited to the following.* Yes No, Call before any diagnostic testing CPR In the event your pet should experience cardiac or respiratory arrest while being treated today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are, also, acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.* I agree to CPR being performed in case of emergency. I elect a “Do not resuscitate” status in case of emergency. For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival. Acknowledgements I am the owner or authorized agent for the pet described above and have the authority to initiate care by executing this consent. By signing this, I certify that I am over eighteen years of age and hereby agree to make myself available by PHONE between the hours of 9:30am – 3:30 pm to aid the doctor with any questions regarding my pet’s history or symptoms. I agree to pay in full today for services rendered on this date, including those deemed necessary for any medical complications or unforeseen circumstances. Furthermore, I understand regardless of the outcome of treatment, I am responsible for payment of the procedures performed today. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner/authorized agent to notify a staff member of such limitations PRIOR to examination or initiation of treatment for my pet. I am, also, aware that a 50% deposit of detailed treatment plan may be required prior to hospitalization or treatment of my pet. I am aware of the right to decline any services prior to them being performed and by doing so a second visit may be required with additional costs added, including but not limited to additional exam fees and diagnostic charges. I understand the practice of veterinary medicine is not an exact science and thus, there are no warranty or guarantees that can be awarded to me as to the results or cure afforded by the treatment or procedures performed here today. I have been awarded the opportunity to discuss any questions I may have regarding the care of my pet to my satisfaction, and it is my responsibility to do so. I accept that my financial obligation remains regardless of any outcome.* I have read and agree. Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.