Affordable Animal Emergency Clinic Medical

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / 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