CAH Canine History Form

Today's Date *

Date

Client Information

Name *

First Name Last Name

Emergency Contact Number *

Secondary Contact Name

First Name Last Name

Secondary Contact Number

Email *

example@example.com

How would you like us to communicate NON- emergency information? *

Address

Street Address

Street Address Line 2

City State

Zip Code

Please list all people authorized to pick up your pet.

Pet's Information

Pet's Name *

Breed *

Sex *

Patient History

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

Please explain reason for visit *

Any long-term/pre-existing medical conditions? *

On any medications and/or supplements? *

Any refills or written prescriptions needed?

What kind of food/treats does your pet eat? *

Eating/Drinking? *

Vomiting and/or diarrhea? If so how long has it been going on? How often? *

On any flea, tick, and heartworm prevention? *

Coughing/sneezing? *

Microchipped? *

If not microchipped, would you like to have it done today?

Does your pet have any medical history/laboratory testing at another clinic? If so, where? *

Would you like your pet to any wellness or senior labwork done today? *

Would you like to have your pet vaccinated for leptospirosis? (Typically for dogs who hike and swim or live near wooded areas) *

Please list any additional information we should know regarding you or 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.

*

I understand and agree to these terms and conditions

Any medical reason your pet should not be vaccinated?

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.

Please select the following: *

I have been informed and understand the importance of regular fecal testing

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.

Please select one *

I GIVE permission for life-saving procedures I DO NOT give permission for life-saving procedures

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.

Please select one *

I GIVE permission I DO NOT give permission

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.

Please Sign *

Clear

CANINE HISTORY FORM