Urgent Care Form

Owner Name
Pet's Name*
Sex*
Age (est. is fine)*
Weight (est. is fine)*
What is the reason we are seeing your pet today?*
When did these symptoms begin?
Have you tried anything at home to treat the issue?
Has your pet been exposed to anything new lately? (New toy, medication, food, got into trash for example)
Have you noticed any behavior changes?
When did your pet last eat?
What do you feed your pet?
Is your pet drinking water?
Is your pet vomiting or does your pet have diarrhea? If so, for how long and what does it look like?
Please list all medications and supplements your pet is currently on,and when did your pet last have his/her last dose? (Including flea/heartworm prevention)
Has your pet been here before? If not, who is your previous vet, and do we have your permission to contact them for history?
Do we have permission to do bloodwork and/or X-rays if the Doctor feels it is necessary?*
- Yes
- No
Do we have permission to treat your pet today based on the findings? Or would you prefer a call first with an estimate of costs for treatment?*
- Yes
- No
Signature*
I am the owner/agent of the pet listed above and authorize an exam for my pet. I understand that payment is due for services when pet is discharged.
Date*
Date Format: MM slash DD slash YYYY
What telephone number can you be reached at today?*
Enter the code below