Drop off Examination Form | Alta Rancho Pet & Bird Hospital

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Client Information:

Name

First Last

Email

Phone number where you can be reached TODAY:*

Best Time:*

: HH

MM

Alternate phone number and/or person to contact:*

Pet's Name:*

Species:*

Specify

Breed:*

Sex:*

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).

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)*

Are any other pets in the house ill?*

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?*

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)?*

If it is medically appropriate, would you like us to vaccinate your pet today?*

Has your pet had a stool examination for parasites within the last 12 months?*

Has your dog been tested for heartworm disease within the past 12 months?*

Has your cat ever been tested for Feline A.I.D.S and/or Feline Leukemia Virus?*

Does your pet have a microchip identification implant?*

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?*