Could not connect to the reCAPTCHA service. Please check your internet connection and reload to get a reCAPTCHA challenge. Client Information:Name First Last Email Phone number where you can be reached TODAY:*Best Time:* : Hours Minutes AM PM AM/PM Alternate phone number and/or person to contact:*Pet's Name:* Species:* Canine Feline Avian Other's Specify Breed:* Sex:* Male Male - neutered Female Female - spayed Age:* Would you like the doctor to give you an estimate of charges before performing any work on your pet?* Yes - Please call me before doing anything. No - Do what must be done and call me later. No - Do what must be done up to a specific dollar amount (you will enter the dollar amount below). No - Call only if the estimate exceeds this (you will enter the dollar amount below). Pet Health Information:Reason for examination:*How long have the symptoms been present? Has the problem been getting worse, better or not changing? Has your pet recently exhibited any of the following signs? (Please check the box and explain below)* Vomitting Diarrhea Coughing Sneezing Difficulty Breathing Weakness Seizures Weight Change Scratching Hair Loss Lameness Change in Thirst or Urine Are any other pets in the house ill?* No other pets No, other pets are O.K. Yes Is your pet currently taking any medication? (Please specify drug name, amount and frequency):Do you know approximately when your pet was your pet last vaccinated?* Yes No Do you know the practice name and/or phone number where your pet was vaccinated? Do you have a copy of your pet's vaccination history with you (if yes, please give it to the receptionist)?* Yes No If it is medically appropriate, would you like us to vaccinate your pet today?* Yes No Has your pet had a stool examination for parasites within the last 12 months?* Yes No Has your dog been tested for heartworm disease within the past 12 months?* Yes No Has your cat ever been tested for Feline A.I.D.S and/or Feline Leukemia Virus?* Yes No Does your pet have a microchip identification implant?* Yes No When was the last time your pet had his/her teeth cleaned?* Would you like the Doctor to give you an estimate for a dental cleaning procedure?* Yes No Download and print form here.
