Illness/Injury Information Form
Owner Name
*
First Name
Owner Name
Pet's Name
*
Pet's Name
Best Contact Number (at time of visit)
*
Format: (000) 000-0000.
Day and time of appointment
*
What is your main concern for this visit?
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How long have you noted the signs related to this issue?
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Less than 24 hours
24-48 hours
Less than 1 week
1-2 weeks
>2 weeks
Other
Please select all of the signs that you have recently noted in your pet:
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Decreased Appetite
Lethargy
Diarrhea
Vomiting
Increased Thirst
Increased Urination
Straining to Urinate
Straining to Defecate
Limping
Yelping/Reacting as if painful
Behavior Changes
Excessive Scratching/Licking
Sneezing
Ocular or Nasal Discharge
Wound
Other
Please give descriptive details about the signs seen (i.e. the diarrhea is very liquid with mucous and seems urgent like (s)he can't hold it; also (s)he has had accidents in the house which isn't normal). The more detail included, the more information the doctor will have, so please be thorough!
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What heart worm and flea prevention is your pet currently taking and when was the last given dose?
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Please list your pet's current prescription medications, if applicable (including preventatives and supplements).
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What, how much, and how often do you feed your pet?
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If your pet is a cat, do they go outside?
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Yes
No
My pet is not a cat
As this visit is for an illness or injury, routine treatments like vaccines may not be advisable. If you would like additional services during this visit (like a nail trim, cytopoint injection or vaccines), please list the requested services here :
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Is there any other information that you would like us to know about your pet or the current situation moving forward?
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If you have been to another veterinary hospital within the past 3 years, please provide their name and contact information so we may obtain records for your appointment.
Lake Austin Blvd Animal Hospital (LABAH) will contact you if additional diagnostics (x-rays, blood work, etc.) are necessary. In the event we cannot get in contact with you, does LABAH have permission to run additional tests?
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Yes
No
If yes, what total bill amount do you approve?
*
Please note, this is not a drop off appointment (unless otherwise specified by staff). Due to limited kennel space in our clinic, we ask that you please remain in your curbside check-in spot for the duration of your pet's appointment. If you leave without notice, a boarding fee of $28.00 will be added to your bill. By signing you agree that all information is true and you understand the fee associated with leaving the property will be added to the final bill.
Submit
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