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): *

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.

urination Diarrhea in

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

Emergency Clinic