Geneva Lakes Animal Hospital Pet Exam Form PDF

Client Name

Telephone Number to reach you today:

Has your pet been seen by us?

Pet's Name

Breed

Age

What are we seeing your pet for today?

What is the name of the food you are feeding? Is it Wet, dry, or both, How much to you feed at each feeding and how many times per day. What was the time of the last meal.

Was this a new bag of food or have you switched food? (If yes when?)

Does your pet get regular treats? Type and Frequency (include table food)

Please list all the medications or supplements your dog receives and/or recently received. Please list; name of medication, milligram strength, Amount given, frequency, time and date last given

What brand of Heartworm prevention do you use?

Last Given

What brand of flea/tick prevention do you use?

Last Given

Is your pet sensitive or allergic to any medications or food

If yes, please list

Cats; Please choose

Other cats in house

Other Cats outside?

Other Pets?

If yes what kind?

Dogs; Please choose

If exposure to wild animals, what kind?

Dogs; please choose

Please choose Vaccines, bloodwork, heartworm test and procedures your pet has had.

Primary Complaints

Other Primary Complaint not listed above

Drinking

Appetite

Urination

Defecation

Weight

In your own words please describe what is going on with your pet. How long has it been going on? Also please let us know of any previous major medical problems, and any history leading up to the current condition

If your pet has any unusual lumps, bumps, wounds, or skin irritation which you would like the doctor to address today, please note the location of each.

Would you like us to?

Additional requests? Any additional Treatments or Vaccinations you would like us to do today?

Are there any medications you would like refilled today? Flea/tick Preventative? Heartworm Preventative

PROFESSSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Geneva Lakes Animal Hospital, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.

Signed

Date

MonthDayYear

* Please note that if we have not seen your pet before, we will need to be able to contact you regarding your pet's examination prior to starting any treatments.

Please mark what you described above.