DROP OFF HISTORY FORM
Please help us to take the best care of your pet possible by providing us with this important information. Thank you!
Pet’s name:
Pet’s breed and color:
Pet’s age:
Please mark any significant problem that applies to your pet:
Itching and/or licking skin
Losing weight
Lethargic
Vomiting
Diarrhea
Shaking head or scratching ears
Limping
Decreased appetite
Please add any additional important details about your pet that we may need to know about your pet:
Please mark the option that describes your pet’s urine and bowel movements:
No change
Increased urine
Formed stool
Semi-firmed stool
Watery stool
What type of food is your pet currently eating?
Has your pet’s food been changed in the past 2 weeks?
Yes
No
Does your pet ever get “people food?”
Yes
No
Where does your pet spend his/her time?
Indoor only
Mainly indoor, occasionally outdoor
Mainly outdoor
Exclusively outdoor
Please describe any lumps or bumps that you would like to be examined:
Is your pet currently receiving a monthly intestinal and heartworm preventative?
Yes, every month
Yes, but occasionally missing a dose
No, not currently
Is your pet currently on any medication?
Please add any comments or questions you may have for the veterinarian:
Name
First Name
Last Name
Please add the best phone number at which you can be reached:
*
-
Area Code
Phone Number
Email
*
example@example.com
Thank you for allowing us to care for your pet today!
One of our veterinarians will examine your pet and call you as soon as they are able.
Medical release:
I hereby consent and authorize the staff of the Saraland Veterinary Clinic to receive, prescribe for, treat, sedate, or operate upon my pet. The undersigned agrees to make payment when services are rendered.
Signature
*
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