Welcome to Capital Veterinary Specialists Urgent Care Service

Welcome to Capital Veterinary Specialists Urgent Care Service - TALLAHASSEE
Please take a moment to give us information about your pet.
Owner Name:*
Address:*
City/State/Zip:*
Primary Telephone #:*
Secondary Telephone #:
Email address:*
example@example.com
(used only for communication from our office)
Pet Name:*
Age:*
Breed:*
Color:*
Sex:*

Male IntactFemale IntactMale NeuteredFemale Spayed
Primary veterinarian:*
Primary Veterinary Hospital:*
What is the reason for your visit? (list symptoms)*
How long has the problem been present?*
Please list any medications your pet is currently taking:*
Is you pet on heartworm preventative?*

YesNo
What kind and when was it last given?*
Flea/tick Brand and when was it last given?*
Has your pet had surgery in the past year?*

YesNo
If yes, when, what type?
Any change in appetite?*

YesIncreasedDecreasedNo change
What do you feed your pet?*
When did your pet eat last?*
Does your pet have any of the following?*

DiarrheaVomitingDifficulty BreathingLimpingExcessive UrinationBlood in stool or urineExcessive urinationDrinking more than usualLethargyHeart MurmurSeizuresOther
Does your pet have any allergies that you are aware of?*

YesNoOther
Any other information we should be aware of?
In the event of cardiac arrest*

I DO want CPR performed on my petI do NOT want CPR performed on my pet
I, the undersigned owner, authorized owner's agent or Good Samaritan responsible for seeking emergency veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination and treatment of this pet by staff veterinarians at this veterinary pratice. I understand that I am financially responsible for these services and that payment is expected at the time of this visit.
Signature*
Date

MonthDayYear
Should be Empty:

Welcome to Capital Veterinary Specialists Urgent Care Service - TALLAHASSEE