test in Lubbock, TX | Hub City Veterinary Clinic

Client Information

Client Name*

First Last

Client Phone*

Client Email

Patient Information

Pet's Name*

Breed*

Age*

Sex*

Reason 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 Habits

What 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.

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*

Date*

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

test

Client Information

Patient Information

Dietary Habits

CPR

Our Location

Address

Like us on Facebook