• CANINE HISTORY FORM

    Please fill out prior to your appointment.
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  • Client Information

  • Pet's Information

  • Patient History

    Write N/A if the question does not apply to your pet.

  • Vaccinations and Parasite-Free Environment

    Please be aware that all pets are checked for fleas and ticks upon admittance. If evidence is found, a Capstar will be given at the owner's expense. All guests must be free of fleas, ticks, and intestinal parasites.

    For the protection of all our patients, all guests must be current on required vaccinations and testing and will be updated at the owner's expense unless otherwise noted below in the space provided. If there are concerns about our requirements, please note that here and you will be contacted by one of our staff members.

  • Zoonosis Informed Consent

    Every year, tens of thousands of Americans will get sick from diseases spread between animals and people. These are known as zoonotic diseases. Zoonotic diseases can be caused by germs including viruses, bacteria, parasites, and fungi. It is important to know that animals do not always appear sick when carrying a zoonotic disease. Many animals can appear healthy, but still be carrying parasites that can make people sick. Stool sample exams, or "fecals," are an important tool to minimize the risk of pets passing intestinal parasites to their owners.  We recommend a fecal be done every 6 months for all pets, including indoor-only animals.

  • In Case of Emergency

    *Should unexpected life-saving emergency care be required and the staff of Cedarcrest Animal Hospital is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services and understand that those fees are not included in my estimate.

  • Photo Release

    I grant to Cedarcrest Animal Hospital, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically.

    I agree that Cedarcrest Animal Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

  • Authorization

    I, the undersigned owner or agent of the owner of the pet identified above, certify that I AM EIGHTEEN years of age or older and authorize the veterinarian(s) at Cedarcrest Animal Hospital to perform the above procedure(s). I understand that some risks always exist with drug therapy and medical treatments and I have been encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

    • The reasonable medical treatment options for my pet
    • Sufficient details of the procedures to understand what will be performed
    • How fully my pet will recover and how long it will take
    • The most common and the most serious side-effects
    • The length and type of follow-up care and home care required
    • The estimate of the fees for all services
    • Any necessary payment arrangements

    While I accept that all procedures will be performed to the best of the abilities of the staff at Cedarcrest Animal Hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for all fees and provide payment via cash, credit card, CareCredit or check at the time my pet is discharged from Cedarcrest Animal Hospital.

  • I have read and fully understand the terms and conditions set forth above.

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