Baeyens Hauk Veterinary Group Appointment Information Form

Baeyens Hauk Veterinary Group
Appointment Information Form
Thank you for dropping off your pet with us today! The following information will be used to help our veterinary team accurately complete your pet's medical needs for today's visit, so please be as descriptive as possible.
Owner's Name
Pet Name
Phone #1 where you can be reached today
Phone #2 where you can be reached today
Reason for visit (MARK ALL THAT APPLY AND IN EXPLAIN IN DETAIL)

Annual VaccinationsBehavioral ConsultationBloodworkWellness ExamWeight ManagementRadiographsDental EvaluationIllness/Injury/ConcernsOther
Illness/Injury/Concerns
Are there any concerns for: (MARK ALL THAT APPLY AND EXPLAIN IN DETAIL)
EX: If not eating, how long, still eating treats? Is patient not eating anything offered or just small meals throughout the day?, ect

Not EatingWeight GainVomitingBad BreathNot DrinkingItching/ScratchingDiarrheaLimpingExcessive drinkingScootingUrination IssuesMasses/GrowthsWeight LossShaking Head/EarsBehavioral ProblemsEyesLethargyDifficulty RisingOther
List all medications/supplements/time given:
Diet/Amount per day:
BHVG has permission to use sedation if necessary?

YesNo
Does BHVG have permission to provide any necessary treatment should an unexpected emergency occur

YesNo
Has your pet ever had an adverse reaction to vaccines or any medications?

YesNo
Please Explain:
Are other pets in household showing similar signs? Please Explain:
*For the protection of your pet and other hospital patients, BHVG will treat when internal or external parasites are present.
*Would you prefer an estimate before any treatments/procedures are performed?

YesNo
*I understand payment for services performed will be due when my pet is discharged. Owner’s Signature:

Clear
Today’s Date:

MonthDayYear
Date
8620 Hwy 107 | Sherwood, AR 72120
Please verify that you are human*
Appointment Location
Should be Empty: