Primary Vet Care - Appointment Information Form

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We have arranged for you to leave your pet here, to allow one of our Doctors to examine your pet as soon as possible today. Please read through the following questions, and answer any that may apply to your pet today. Please read and sign the authorization on the back of this form.
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Owner
Email
Pet
Weight
Age
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Have you or a member of your household been sick in the last 14 days?(this is for general safety so additional precautions can be taken)
Yes
No
4
Everything was okay with my pet until
Since then
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What medications (if any) has your pet received in the last 24 hours?
Name of medication
Amount given
What time
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2
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Name of medication
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Amount given
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What time
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Name of medication
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Amount given
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What time
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Name of medication
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Amount given
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What time
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Please Select the appropriate or describe to the best of your knowledge
Please Select
Please Select
Yes
No
Is your pet sensitive or allergic to any medications or food
Please Select
Please Select
Yes
No
My pet is lethargic
Please Select
Please Select
Yes
No
Is your pet eating normally
If no, has not eaten since
Please Select
Please Select
Yes
No
My pet is vomiting
If yes, It started on
and the last vomit was on
Describe the vomit ( color, was it food, liquid, foamy,etc?
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Please Select
Please Select
Decreased
Increased
Unchanged
Water intake has
Please Select
Please Select
Yes
No
My pet is having diarrhea
If yes, It started on
Describe the diarrhea
Please Select
Please Select
Yes
No
My pet seems constipated
If yes, The last stool was on
Has your pet had access to foods other than recommended pet food?
Is your pet indoor/outdoor/both?
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Please Select
Please Select
Lost Weight
Gained Weight
My pet has
Please Select
Please Select
Lame
Sore
Has been injured
My pet is
Since
I think his/her ( fill in with appropriate body part) is bothering him/her.
This started
It has worsened / improved some?
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This has never happened / has happened before, it happened on
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Please describe in next text box, in your own words what seems to be the problem and watch the body part on the diagram that you think is the problem.
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Please describe the problem according to diagram
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I am the owner/agent for described animal, authorize, and request an exam for my pet. I understand that sedation and/or pain medication will be provided if deemed reasonable. I understand PCAH doctors will contact me after she has examined my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges. I can be reached at
Number
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If I cannot be reached at this number, initial diagnostics, including radiographs, and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and other supportive medications be started as indicated for my pet.
I AUTHORIZE
I DO NOT AUTHORIZE
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Initials
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......anesthesia, surgery and medications if needed for abscess, laceration or other wounds, if my pet is presented for one of these problems. I understand, and accept that when anesthesia is involved, there are always inherent risks,including death. I have read and understand this risk.
I AUTHORIZE
I DO NOT AUTHORIZE
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Initials
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I understand payment is due when my pet is discharged, however, a deposit may be
required after an estimate is prepared and discussed. I accept financial responsibility for
charges incurred for this pet.
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Signature * This field is required.
Clear
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Date * This field is required.
Date
Year
Month
Day
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