The information requested would tell us the things you want us to do for your pet.    Therefore, it is very important for you to be as specific as possible.  Thank you.

OWNER’S NAME:___________________________   DATE:_____________

PET’S NAME:_______________________________

Is there a problem with your pet that you would like for us to look at? Yes (  )  No(  )

When did you first notice this problem?________________________________________

Is your pet on any type of special diet food? Yes(  )  No(  )

If so, what kind?_________________________________________________________

Does your pet have any vomiting? Yes(  ) No (  )

If so, how long?__________________     

Normal  bowel movements? Yes(  )  No(  ) If No how long? ______________________

Is your pet having any of the following symptoms:

Drinking more water Yes(  ) No(  )  How long?_________________________________

Listless    Yes(  )  No(  )   How long?_________________________________________

Coughing Yes(  ) No(  ) Sneezing? Yes(  )  No(  )How long?_______________________

Sneezing? Yes(  ) No(  ) How long?__________________________________________

Gagging? Yes(  )  No(  ) How long?___________________________________________

Scratching? Yes(  ) No(  ) How long?__________________________________________

Shaking head? Yes(  ) No(  ) How long?_______________________________________

Limping? Yes(  ) No(  ) How long?___________________________________________

Urinating Normally? Yes(  ) No(  ) If No Explain________________________________

Seizures? Yes(  ) No(  ) How long and often?___________________________________

Bad Breath? Yes(  ) No(  ) How long?_________________________________________

Weight loss or gain? Yes(  ) No(  ) How long?__________________________________

Any lumps or bumps? Yes(  ) No(  ) Where?________Have they gotten any larger?_____

Unusual discharge? Yes(  ) No(  ) Where?______________ How long?_______________

Behavioral changes? Yes(  ) No(  ) Please describe?______________________________

Is there anything else that we need to know about your pet? Yes(  ) No(  )

After a thorough examination and assessment by the Doctor, you will be contacted to discuss diagnostic and /or treatment options that are in the best interest of your pet.  Please leave us an accurate phone number where you can be reached at any time during the day.  We ask that you provide more than one phone number if possible.  If you have not heard from our office within a few hours of having dropped your pet off, please give us call, as we may be having trouble reaching you.  We will not proceed with diagnostic and/ or treatment without discussing all possible options with you first!

Signature:___________________________ Date:___________________________ Phone No.___________________________ Please provide the no. you will be at in the next several hours.  You can provide more than one number if needed.