|Owner Phone Number (required)|
|Primary Contact Name and Phone Number on appointment day (if different from Owner Name) (required)|
|Pet's Name (required)|
|Reason for Visit - My pet is here today for (required)|
|Overall well-being, weight, appetite, thirst, and eliminations (required)|
|If Abnormal, explain|
|Daily diet (brand + dry or canned), frequency of feeding, and when your pet last ate (required)|
|List medications you are currently administering to your pet, including heartworm prevention, flea control, supplements, and when dose(s) were last given (required)|
|I need the following medication(s) refilled (required)|
|-> **FOR ILLNESS VISITS or FOLLOW-UP ONLY: Please explain the problem *and* how long it has been going on (and if the patient is doing better, worse or the same)|
|For vaccine appointments: Has your pet had prior reactions to the requested vaccines or treatments?|
|Cats Only -- My cat primarily lives|
Day Patient ("Drop Off") Information
If you require an estimate, please discuss this with a service representative or nurse *before* dropping off your pet.
Day patient discharge times are typically between 4 and 6 p.m. Please do not pick up your pet until a doctor or nurse has communicated with you that your pet is ready. We are unable to guarantee a specific discharge time due to the veterinary team's surgery, inpatient, and urgent patient priorities. Thank you for your understanding.
**Day patients are evaluated (triaged) based on severity/complexity of the problem, then by order of arrival. Critical and anesthetic/surgery patients receive priority attention. Thank you for understanding. **
CPR Authorization: In the unlikely event that complications develop and your pet’s breathing and/or heart stop while in our care, do you want us to perform CPR (resuscitation)?
(** Please understand that in the event your pet requires CPR, additional charges will incur for treatments utilized during CPR.)
|Client/Authorized Signature (Please type your first and last name) (required)|