Owner's Name:

Pet's Name:

Phone Number:

Please check the signficant problems that apply to your pet:

How long has your pet been displaying these symptoms?

My pet is urinating:

My pet is defecating:

Normally

Soft Stool

Liquid/Watery Stool

Hard/Dry Stool

What are you currently feeding your pet?

Appetite:

Have you recently changed foods?

If you have recently changed foods, what were you previously feeding?:

How much and how often are you feeding your pet?

Where does your pet spend his/her time?

Does your pet have any lumps, bumps, cuts, or sores you would like examined? Please note specific places these can be located.

Is your pet currently receiving a monthly intestinal parasite and heartworm preventative? If yes, what type & how often?

Is your pet currently receiving a flea/tick preventative? If yes, what type and when was the last dose?:

Is your pet currently receiving any other medications? Please list medications and daily doses even if prescribed by our hospital:

Baseline costs for diagnosing/treating a sick patient may be approximately $350 in addition to the physical exam. Do you give permission to proceed with doctor recommended diagnostic testing?

Please list any other comments or questions you may have for the doctor:

Free Text

Drop off exams are offered for your convenience. Your pet will be examined when the doctor's schedule allows. (Critical patients will be examined immediately). Pick up times cannot be guaranteed, but we will try our best to accomodate your schedule.

Drop Off For

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