Patient Exam Request

Patient Exam Request

Please complete the following as thoroughly as possible so the doctor can accurately diagnose your pet’s condition. We will call on the phone number below to discuss any questions or findings.
PLEASE NOTE: Due to CV19 you may experience longer than usual wait times. We greatly appreciate and thank you for your patience and understanding as we continue to work hard to provide you and your pet the absolute best care possible!
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Pet's Name *
Species *
Reason for visit *
Name/Brand of Food Currently Feeding? *
Current diet? (Canned or Dry) *
Amount/Frequency Fed Per Day? *
Is your pet current on the following preventatives? *

Heartworm Prevention Flea/Tick Prevention My pet is not currently on Flea/Tick or Heartworm Prevention
Other Current Medications (If applicable)
Please provide name and dosage information.
Does your pet require any medication/diet refills today?
Please provide name of medication and quantity requested.
Have you noticed any of the following symptoms? (Please select all that apply) *

Coughing Sneezing Vomiting Diarrhea Decreased/Increased Thirst Decreased/ Increased Appetite Decreased/Increased Urination Urinary Issues Painful Lethargic/Decreased Energy Levels Nasal Discharge Eye Discharge Ear Discharge/Odor/Itchiness Skin Issues/Odor Limping/Mobility Issues New Lumps/Bumps Changes in Behavior or Mood No Changes or Issues Noted
Please describe in detail any issues selected above:
When did the current problem begin?
Would you like the following performed if your pet is due?

Heartworm/Tick Disease Screen Fecal Screening Wellness/Senior Bloodwork* Vaccine Updates Felv/FIV testing (cats only)
* Please note, if your pet requires senior bloodwork, this requires a urine sample. Please bring a sample with you at the time of your appointment. A sample collected prior to your appointment may be stored in the refrigerator up to 12 hours.

* If you are unable to collect a sample at home, we may collect a sample at your appointment for an additional charge. Please call our hospital with any questions.
Does your pet have Pet Insurance? *
If yes, name of Insurance Company?
Pet Insurance Policy #:
Any additional questions/concerns you would like the doctor to address today?
Do you or anyone in your family, have peanut/food allergies? * We frequently use peanut butter or other food based items as a patient treat as per Fear Free guidelines *

YES NO
If 'YES' please note allergens below:
Treatment Authorization (Please choose one of the following): *

I authorize treatment, x-rays, or lab work if the doctor considers this necessary to diagnose the condition(s) above. I wish to discuss any findings/recommendations with the doctor before any additional testing or treatments are performed.
Should be Empty:

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