Date* Date Format: MM slash DD slash YYYY Name of Pet*Age*Sex*MaleFemaleNeutered*YNMEDICAL HISTORYDoes your pet have any past medical problems*YNIf yes please explainCan we send for records from your previous veterinarian*YNName of previous veterinary hospitalAre there any problems that need addressing today?*YNIf yes please explain ( first noted, duration)Is your pet*INDOOR ONLY (no outside contact)OUTDOOR ONLYCOMBINATION INDOOR/OUTDOORIs your pet exposed to other dogs?*YNIf yes, where? (select all that apply) GROOMING FACILITIES BOARDING FACILITIES DOG PARKIs your pet exposed to ticks?*YNIf yes, where? (select all that apply) IN BACK YARD BRIONES MARINA LYME RIDGE LAFAYETTE RESERVOIR OTHERWhere?If you marked yes your pet should be vaccinated for Lyme disease. If your dog is due or at risk can we administer the vaccine?*YesNoWish to discuss w/ DrIs your pet exposed to any standing bodies of water (cow ponds, ponds that raccoons and other wild animals have access to)?*YesNoIf you marked yes your pet is at risk for Leptospirosis, a disease transmitted through urine. If your dog is due or at risk can we administer the vaccine?*YesNoWish to discuss w/ DrHas your pet recently had any of the following: (select all that apply) VOMITING (digested food, liquid, blood, color) DIARRHEA (liquid, loose, blood or mucus, color) COUGHING (how often/long has pet had cough) SNEEZING (how often, nasal discharge, color)If yes to any of the above please explain (problem first noted, duration, consistency, etc.)Appetite*NormalAbnormalincrease or decrease, durationWater Intake*NormalAbnormalincrease or decrease, durationUrination*NormalAbnormalfrequency, color, straining, etc.DietWhat Brand Dry?*How much do you feed per day?*What Brand Wet?*How much do you feed per day?*CURRENT MEDICATIONSHeart worm Prevention*YNIf yes what Brand and how often?Flea Prevention*YNIf yes what Brand and how often?Other Medication*YNIf yes give names, strength, how often and when last given.In accordance with the recommendations of the Center for Disease Control we recommend yearly heartworm testing and bi-annual stool testing for intestinal parasites. If your pet is due for either of these lab tests can we perform these services?*YesNoWish to discuss w/ DrAUTHORIZATIONWhat number can we reach you at in the next 24 hrs?*If any non-emergency problems are found by one of our veterinarians which would your like us to perform?*I authorize up to $ (select amount below) for the treatment of my pet.I would like to further discuss treatments to my pet before administered.Select amountDate* Date Format: MM slash DD slash YYYY Signature*IF YOUR PET IS DUE FOR VACCINES AND NO VETERINARY EXAM HAS BEEN GIVEN TO YOUR PET IN THE PAST 30 DAYS (or you have no proof of a current exam), A EXAM FEE WILL BE CHARGED PER PET.BOARDING PATIENTS ONLYHow long will your pet be staying with us? From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY We require Dogs to be current on Rabies, DHPP, and Bordetella, CIV (K9 Flu) vaccines. Do you have proof of current vaccines?YesNoIf no we will vaccinate your pet here.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
