Drop Off Dropping off your pet for an exam? Please fill this out to help us better assess any concerns. Date MM slash DD slash YYYY Drop Off Exams are offered for your convenience. Your pet will be examined when the doctor's schedule allows. Pick up times cannot be guaranteed, but we will try our best to accommodate your schedule. Thank you for allowing us to care for your pet today!Name First Last What is your main concern today? Please include details to help us better assess your pet.Please check the significant problems that apply to your pet. Coughing Lethargic Sneezing Seizures Eye Discharge Difficulty Defecating Difficulty Eating Losing Weight Gaining Weight Scratching Ears Shaking Head Vomiting Itching Limping How long has your pet displayed these problems? Is your pet on any medications? Describe your pet's appetite and drinking habits. Describe your pet's urine and bowel habit. No Change Increased Urine Decreased Urine Increased Stool Formed Stool Semi-Formed Stool Watery Stool What are you currently feeding your pet? Dry Food Canned Food Dry Food + Canned Food People Food What brand of food are you feeding your pet? Is this a recent change? If yes, what were you previously feeding? Please list locations of any lumps/bumps that you would like checked Where does your pet spend his/her time? Only Indoor (NEVER Outside) Mainly Indoor Mainly Outdoor Equally Indoor/Outdoor Is your pet currently receiving monthly intestinal and heartworm preventative? If yes, what kind? In order to diagnose your pet's condition, in addition to your exam, your pet may require sedation ($45-$89), bloodwork ($158-196), x-rays ($175), and/or other diagnostic testing. Please select tests you authorize the doctor to perform if they feel they are warranted. Select All Sedation ($50-$95) Blood work ($168-$206) X-Rays ($193) Please contact me prior to performing any testing. In order to diagnose your pet's condition, in additional to your exam, your pet may require sedation, blood work, x-rays, and/or diagnostic testing.PhoneIt is very important that the doctor is able to contact you if they have any questions regarding your pet. If the doctor is unable to reach you, it may result in a postponement of treatment. Please list all phone numbers where you can be reached today.Additional PhoneConsent* By checking this box, you understand and agree to what you provided above. Δ
