"*" indicates required fields Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.Owner Name* First Last Phone*Email* Pet's Name*Who should we contact to make medical decisions today?* Owner (Named Above) Someone Else (Named Below)Who should we contact to make medical decisions today?* First Last At what number can they be reached today?*Reason for visit: (check all that apply)* Vaccine booster, please specify which one(s) below Anal gland expression Nail trim Ear cleaning Blood testing previously recommended by veterinarian Urine testing previously recommended by veterinarian Heartworm/Tick test (dogs) Fecal/Intestinal parasite screen SQ fluid therapy Cytopoint injection Laser therapy treatment OtherPlease specify which vaccine booster(s)If Other, please explain:Dog vaccines DHPP Lepto Rabies Lyme Bordetella Canine InfluenzaFeline Vaccines FVRCP/Distemper Rabies Feline Leukemia (FeLV)Flea/Tick/HW prevention: Simparica TRIO (monthly oral flea, tick, and heartworm prevention for puppies over 8 weeks and adult dogs) Revolution PLUS (cats) MilbeGuard (heartworm prevention for dogs) ProHeart (6 month injectable heartworm prevention for dogs) Simparica (monthly oral flea/tick prevention for dogs) Seresto collar (dogs or cats) NoneAre there any additional questions or concerns?Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?* Yes NoIf Yes, please elaborate:*Is your pet on any medications?* Yes NoIf Yes, please list all medications (prescribed or over the counter) and the time of last administration:Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations.I understand that financial responsibilities for services are rendered at the time of discharge.* I have read and understandI give HubCity Veterinary Clinic authorization to treat as discussed above.* I have read and agreeMany of our patients love peanut butter as a snack while visiting our office, but if you or your pet have an allergy to peanut butter, please let us know.Can your pet have peanut butter?* Yes NoHave you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?* Yes NoHave you or anyone in your house experienced the following symptoms in the past 14 days? Cough Shortness of breath Fever Sore throat Chills Muscle pain Headache New loss of taste or smellWho experienced these symptoms? Self Someone else in the house No symptoms*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.Critter concierge: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from the car and support them through the exam, any services required, and then bring them back to your vehicle at the end of the appointment. Unless otherwise noted, your pet’s care will be performed while you remain in the parking lot. A veterinarian or nurse will call you in your vehicle to discuss your pet’s exam and discuss recommended treatments or preventative measures.* I have read and understand. Communicating during the appointment: Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who collects your pet from the car and the receptionist who answers the phone when you first arrive.* I have read and understand.Social Media/Photo Permission: Do we have your permission to post photos of your pet online?* Yes NoSignature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
