Affordable Animal Emergency Clinic Medical

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Pet's Name*

HAS YOUR PET HAD... Please answer YES or NO. If your answer is YES, Please explain. Allergies to meds / food? If yes, list the name:*

Have rabies vaccination w/in the last 3 years?*

Have yearly vaccination w/in the last year?*

Any recent anesthesia or sedation, if YES, when? *

Any recent surgery or dentistry? Date?*

Any recent physical examination? Date?*

Any previous medical workup or test? Date?*

Contact with an animal with a known illness? Date?*

A recent pregnancy or heat period? Date? *

Food eaten or available within the last 6 hours? Time? *

A Feline Leukemia Test (if a cat)? Results? Date? *

Any previous medical conditions?*

If yes, list the medical conditions, medications and dosage. *

Have any cough, shortness of breath or tiring easily?*

Change in appetite or eating habits?*

Vomiting, diarrhea or constipation?*

Increased thirst or excessive urination? *

Blood in urine, stool or other discharge? *

Unusual attitude, fainting or seizure? *

Swelling, limping or pain when moving? *

Itching, hair loss, sneezing, eye or ear discharge?*

Is your pet indoor, outdoor or both?*

Problem or reason for bringing your pet to the Emergency Clinic?*

Any home remedies? What and when? *

Name of Responsible Party: *

Pet's Medical Record