<h1>Non - Surgical Form</h1>

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General Information
Owner Name
Chart (Number)
Patient Name
Age
Sex
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SymptomsPlease check all symptoms that apply to your pet upon admittance to the hospital today
Check
When Noticed First
Duration
Not eating
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Not drinking
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Drinking too much
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Lethargic
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Restless/Will not lay down
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Not urinating
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Urinating too much
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Not defecating
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Diarrhea
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Limping
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Row 9, Column 2
Vocalizing/”crying” in pain
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Shaking head
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Itching
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Vomiting
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Row 13, Column 1
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Swollen limb/face
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Coughing
Row 15, Column 0
Row 15, Column 1
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Sneezing
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Row 16, Column 1
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Not eating
Not drinking
Drinking too much
Lethargic
Restless/Will not lay down
Not urinating
Urinating too much
Not defecating
Diarrhea
Limping
Vocalizing/”crying” in pain
Shaking head
Itching
Vomiting
Swollen limb/face
Coughing
Sneezing
Check
Row 0, Column 0
When Noticed First
Row 0, Column 1
Duration
Row 0, Column 2
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Row 1, Column 0
When Noticed First
Row 1, Column 1
Duration
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When Noticed First
Row 2, Column 1
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When Noticed First
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When Noticed First
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When Noticed First
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When Noticed First
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Row 7, Column 0
When Noticed First
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When Noticed First
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Row 9, Column 0
When Noticed First
Row 9, Column 1
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When Noticed First
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Row 11, Column 0
When Noticed First
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When Noticed First
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Row 13, Column 0
When Noticed First
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Row 14, Column 0
When Noticed First
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When Noticed First
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1 of 17
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If Itching, where? (If not please skip)
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If Other Symptom, Please specify (If not please skip)
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I have received a written Treatment Plan of the costs involved. IT IS ONLY AN ESTIMATE. If further treatment becomes necessary, the cost will change. I may get an update at any time by calling the office between 9am and 4:30pm. There is no payment plan available within the clinic but we do accept cash, credit cards and checks. All balances are due at the time services are rendered.
Initial
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If I have not already received a Treatment Plan for my pet, I will be contacted after the examination, by the medical staff, with an estimated amount of treatment, at the phone number provided. If I cannot be reached at the given phone number or I have not signed the Treatment Plan and/or placed a deposit on my account, treatment will not be provided. I understand the initial examination obligates me to a fee of $38.00.
Initial
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Has your pet ever had any reactions to anesthesia
Yes
No
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If yes, when and drug name?
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If cardiac and/or respiratory arrest occurs (that is, if a pet stops breathing and/or his/her heart stops beating) then cardiopulmonary resuscitation (CPR) will be performed to revive the pet upon your request.
I authorize CPR to be performed on my pet and I agree to any resulting charge.
I decline CPR to be performed on my pet (DNR) and I understand what this means.
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Owner Signature* This field is required.
Clear
11
Date* This field is required.
Date
Year
Month
Day
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I have the authority and I release my pet, Patient Name , to the care of Groves Veterinary Clinic. I realize that results cannot be guaranteed and I assume all risks of treatment and failure to follow post operative care recommendations including cage rest and the use of an e-collar. Without an e-collar, your pet is capable of scratching, biting and traumatizing the treatment site impeding recovery and possibly leading to secondary infection and the need for additional treatment at an additional cost to you. An e-collar must be worn until full recovery is achieved.
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Owner Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
15
Best Contact Number
Secondary Number
Email
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