Name *

Pet Name *

Best phone number to reach you today *

Okay to text? *

Yes
No

Reason for today’s visit *

Has your pet had any of the following symptoms?

If yes, please explain (frequency, duration, etc.)

Change in appetite *

Yes
No

If yes, explain (frequency, duration, etc): *

Change in drinking *

Yes
No

If yes, explain (frequency, duration, etc): *

Diarrhea *

Yes
No

If yes, explain (frequency, duration, etc): *

Vomiting *

Yes
No

If yes, explain (frequency, duration, etc): *

Coughing *

Yes
No

If yes, explain (frequency, duration, etc): *

Sneezing *

Yes
No

If yes, explain (frequency, duration, etc): *

Change in urination *

Yes
No

If yes, explain (frequency, duration, etc): *

Change in activity level *

Yes
No

If yes, explain (frequency, duration, etc): *

Back or leg pain *

Yes
No

If yes, explain (frequency, duration, etc): *

etc):

History of seizures *

Yes
No

If yes, explain (frequency, duration, etc): *

Allergies *

Yes
No

If yes, explain (frequency, duration, etc): *

Cats only:

Does your pet go outside?

Yes
No

If yes, explain (frequency, duration, etc): *

What diet does your pet eat? (Please list the brand, volume, and frequency) *

Is your pet currently on any medications or supplements? (Including heartworm and flea prevention) If so, what and when were the last doses given? *

In the unlikely event of an emergency, would you like us to perform CPR on your pet? *

YES, I authorize CPR or other procedures necessary for the wellbeing of my pet.
NO, I decline any emergency treatment if complications develop.

Authorization to treat *

I authorize the veterinarian to examine my pet. PLEASE CALL BEFORE any diagnostic testing and treatment.
I authorize diagnostic tests and/or treatment NOT TO EXCEED $500.00 as recommended by the veterinarian without telephoning me, including laboratory tests and radiographs.
I authorize ANY diagnostic tests and/or treatment recommended by the veterinarian without telephoning me, including laboratory tests and radiographs.

Signature *

Clear Signature

Date *

Sick Pet Drop Off Questionnaire

Sick Pet Drop Off Questionnaire

Has your pet had any of the following symptoms?

Ready to Visit

Get in Touch

Hospital Hours

After Hours Emergency Care