Talega Animal Hospital - Drop Off Exam Form

1
* This field is required.
Name
Phone number
Email
Pet Name
2
Please provide a detailed description of the presenting problem(s) to aid in the doctor's examination, including symptoms and duration of symptoms.
3
Please let us know how your pet is doing in the following areas
Coughing
Sneezing
Vomiting
Diarrhea
None of the above
4
If so, please explain
5
Please Select
Please Select
Excessive
Normal
Decreased
How is his/her appetite
Please Select
Please Select
Excessive
Normal
Decreased
How is his/her water intake
What is his/her current diet?
Please Select
Please Select
Normal
Lethargic
Hyper
How is his/her energy level
Please Select
Please Select
YES
NO
Is your pet currently taking medications? Please include any flea and/or heartworm prevention as well
6
If so please list
7
Once the physical exam is complete, one of our staff members will contact you with recommended treatment plan for presenting problem(s). I hereby authorize an examination with the fee of $68.00 and I am aware that there may be additional treatments and fees after the initial examination fee. Please be aware pet can be here until 5:30 p.m. weekdays and Saturday until 2:30 p.m.
8
Signature* This field is required.
Clear
9
Date* This field is required.
Date
Year
Month
Day
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