Owner's Full Name *

First

Last

Pet's Name *

Date *

Is your pet mainly: *

Indoors
Outdoors
Both

What do you currently feed your pet? *

How much & often do you feed your pet? *

Are there any other pets in the household? *

Yes
No

If yes, what type of pets?

Are all of your pets up to date on their vaccines and preventative such as, Heartworm and Flea/Tick Prevention? *

Yes
No

*If the pet is not up to date on any of the required vaccines, they will have to be brought up to date at the owner's expense, unless our veterinarian decides otherwise.

Canine Required Items/Vaccines to Stay: Up-to-Date Wellness Exam, DAPP+L (Lepto Separate or Combined), Bordetella, Rabies

Feline Required Items/Vaccines to Stay: Up-to-Date Wellness Exam, FVRCP, Rabies

*Free from Fleas and Ticks, if one of our Team Members notices activity, your pet will be treated ASAP at owner's additional expense.

Names of the preventative given and when were they given each last: *

Is your pet on any medications? *

Yes
No

If yes, list any and all medications and how often they are given:

Has your pet had an allergic reactions before? *

Yes
No

If yes, can you elaborate more?

Reason for Drop-Off *

What is the problem and when did it start? *

Has the patient had this problem in the past? *

Yes
No

Has the Patient had any recent dietary changes (i.e. change in food brands, had food scraps from the table, or treats etc.)? *

Yes
No

If yes, explain:

Has the patient gotten into anything, been exposed to anything, or chewed up anything that he/she shouldn’t? *

Yes
No

If yes, explain:

Is the patient vomiting? *

Yes
No

If yes, how often and what does it look like?

Does the patient have diarrhea? *

Yes
No

If yes, how often and have you seen blood?

Is the patient eating? *

Normal
Less than normal
More than normal
Not eating at all

Is the patient drinking? *

Normal
Less than normal
More than normal
Not drinking at all

Is the patient sneezing or coughing? *

Yes
No

If yes, which one and how frequently?

Is the patient urinating? *

Normal
Less than normal
More than normal
Not urinating at all

Have you seen blood in the urine? *

Yes
No

Is the patient itching and/or scratching? *

Yes
No

If yes, where and elaborate

Is the patient shaking his/her head due to their ears bothering? *

Yes
No

Is there any smell or discharge coming from ears? *

Yes
No

Has the patient lost or gained weight recently? *

Yes
No

If yes, elaborate

Is there anything else we need to know about the patient's medical history? *

ADDITIONAL LAB WORK OPTIONS

Do you want any other diagnostics? Additional fees will apply.

Yes
No

Further blood test (i.e. comprehensive chemistry panel, CBC, urinalysis or specialized test for medications) *

Yes
No

Please list any additional concerns regarding your pet you would like for us to address* *

DISCLAIMER TO CLIENTS

Drop off services at times require blood work, X-rays, and/or possible hospitalization. In such cases, prices will vary. Please check the box that best fits your needs: *

If such items are needed, do them without calling.
Call Me first if such items are needed.

Note that not being able to reach you can and will delay your pet’s treatment. Our veterinarians reserve the right to proceed with such services if deemed medically necessary at the owner's expense regardless of whether contact is made or not.
Drop-off services typically require the patient to be released towards the end of the business day (5:00 PM – 6:00 PM) regardless of the time of intake.
Drop-off services require at times a 50% down payment at the time of drop-off, see management for more details.

Phone number where pet owner can be reached today: *

Email where pet owner can be reached today:* *

By typing your full name in the box below, you attest being 18 years or older and agreeing to the terms and conditions and disclaimers on this form. *

Owner or Agent's Electronic Signature: *

Clear Signature

Please do not submit any Protected Health Information (PHI).

Online Form

Sick or Injury Drop-off Form