Consultation Form

Owners Name*

First Last

Vehicle Color/Make

Date*

Address*

Street Address City State ZIP Code

Phone*

Email*

Pet Information

Name*

First

Breed*

Sex*

Male
Female

Spayed or Neutered*

Yes
No

Age/DOB*

Approximate dates are acceptable

Phone where you can be reached today

* If different than you primary contact phone number

Is your pet sick?*

Yes
No

Major Health Complaint

When did this start?

Has your pet been treated for the same condition recently?

Yes
No

If this is a re-check, is the problem better? Explain below

What brand of dog food is your pet on? Include the amount of food per day

How many times per day do you feed?

Does your pet get table food/human food?*

Yes
No

Is your pet on heartworm preventative?*

Yes
No

What heartworm product?

Medical History

Any injury or accident in the past 30 days?*

Yes
No

What Type Of Injury / Accident

Had any surgery in the past 30 days?*

Yes
No

What Type Of Surgery

Allergic To Any Medications/Vaccines?*

Yes
No

Allergic To What Type Of Medications/Vaccines?

Currently on any medications/vitamins/OTC?*

Yes
No

What Type Of Medications/Vitamins/OTC?

Appetite normal?*

Yes
No

Vomiting?*

Yes
No

Diarrhea?*

Yes
No

Details regarding issues with Diet, Vomiting or Diarrhea

Please include how long the symptoms have been noticeable

Drinking more or less water than usual?*

Yes
No

Weakness?*

Yes
No

Coughing?*

Yes
No

Sneezing?*

Yes
No

Gagging?*

Yes
No

Details regarding issues with drinking, weakness, coughing, sneezing or gagging

Please include how long the symptoms have been noticeable

Urinating more or less than usual?*

Yes
No

How long have you noted the excessive urination

Scratching*

Yes
No

Scratching: Where and for how long have you noted excessive scratching

Shaking head?*

Yes
No

How long have you noted a shaking head?

Limping? Which leg?*

How long have you noted the limp?

Scooting?*

Yes
No

How long have you noted scooting?

History of seizures?*

Yes
No

Explain in detail any history of seizures

Unusual lumps/bumps?*

Yes
No

Explain in detail any unusual lumps/bumps

Unusually Bad Breath*

Yes
No

How long have you noted bad breath?

Weight Loss or gain?*

Yes
No

When did you notice weight changes and describe changes in detail

Unusual discharge?*

Yes
No

How long have you noted unusual discharge and where?

Did the pet eat this morning?*

Yes
No

Anything else we need to know?

Responsibilities and Liabilities

The clinic and staff will not be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that any problem that develops with my pet while I’m absent will be treated as deemed best by the staff veterinarians and I ASSUME FULL RESPONSIBILITY for the treatment expense involved. If I neglect to pick up my pet within 5 days of the date below and do not notify you within that time frame, you may assume that my pet is abandoned and are hereby authorized to dispose of my pet as you deem best and/or necessary.

Signature

I agree to the terms outlined on this form

Yes

Date

Consultation and Medical History Form

Pet Information

Medical History

Responsibilities and Liabilities