Patient History Form Patient History Form Your Name * Your Name Your Name Your Name Email * Best Phone Number to Reach You * Secondary Phone Number How would you like us to contact you? * Phone Call Text Message Email What is the Primary Reason for your pet's visit? * Is your pet experiencing any of the following symptoms? Check all that apply: * Vomiting Diarrhea Constipation Increased appetite Decreased appetite Abnormal urination Increased drinking Lethargy Lameness Change in behavior Crying or whimpering Excessive panting Coughing, wheezing, choking, or gagging Sneezing Tremors or seizures None of the above Please provide more detail (how long, frequency, etc) of the symptom(s) you selected above: * Is your pet experiencing any of the following symptoms? Check all that apply: * Shaking head or ear odor Scooting rear Hair loss Rash Itching or scratching Lumps or bumps Unusual discharge None of the above Please provide more detail (how long, frequency, etc) of the symptom(s) you selected above: * Please list all medications your pet is currently receiving. Please include all prescription and over the counter medications. * What is your pet's current diet? Brand and type of food? Amount given a day? Amount of treats given a day?: * Urgent Blood Work: If your pet is being brought in for vomiting, diarrhea, lethargy, decreased eating, decreased drinking, or on another urgent basis; running a blood profile in clinic will be an important part of the diagnostic process. Please indicate below whether we can proceed with blood work. * YES - Prices vary based on recommended testing depending on patients' symptoms (Example: For a comprehensive panel, CBC, and UA Total= $399) NO Call with cost prior to any diagnostic testing being performed Not Applicable - My pet is in for a wellness visit and not exhibiting any of the above symptoms. Routine Lab Work: If your pet is coming in for their annual visit please check the lab work. * Canine: Adult wellness with intestinal parasite screen and heartworm testing: $180 (Recommended for patients 1-6 years old) Canine: Senior wellness with urinalysis, T4, intestinal parasite screen, and heartworm test: $337 (Recommended for patients 6+ years old) Canine: Intestinal parasite screen and heartworm test ONLY: $111 Feline: Adult wellness with intestinal parasite screen $169 (Recommended for patients 1-6 years old) Feline: Senior wellness with urinalysis, T4, and intestinal parasite screen $309 (Recommended for patients 6+ years old) Feline: Intestinal Parasite Screen Only $68 Call before proceeding with blood-work Not Applicable If your pet is being seen for lameness, coughing, difficultly breathing, vomiting, abnormal urination, constipation or other Gastrointestinal issue, x-rays will be an important part of the diagnostic process. Please indicate below whether we can proceed with x-rays. * YES - Initial cost of x-rays is $325, this includes up to 3 views NO Call before proceeding with x-rays Not Applicable - My pet is in for wellness visit and not exhibiting any of the above symptoms. In the event further diagnostics and/or treatments are needed, please indicate how you would like us to proceed. * Perform any additional diagnostics and/or treatments. Call or text me first. If you cannot reach me, you may proceed with any diagnostics and/or treatments deemed necessary. Do nothing else unless you contact me. Must Have Proof of Current Rabies Certificate (Rabies tags DO NOT count as proof) * If you cannot provide proof of rabies certificate, your pet will be given the vaccine and you will be charged $15. All animals over 12 weeks are required by law to be up to date on rabies. Signature * signature keyboard Clear Date * Captcha If you are human, leave this field blank. Submit
