FMC- General History Form

General History Form

**This form should only be filled out if you already have an appointment scheduled. If you need to make an appointment, please call us at 281-480-5500 or click the "Book Appointment" link on our website.** Please complete this form to the best of your ability to help ensure accurate and efficient examination and treatment of your pet. While the information on this form is very helpful, the technicians and doctor will have additional questions so that we may provide the best possible care for your cat.
Curbside appointments are still available on request.
Owner's Name

First NameLast Name
Have you had a change in your mailing address since your last visit or since filling out our New Client form?
New Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Owner's Email
example@example.com
Primary Phone Number (Please enter the best number to reach you at on the day of your appointment. We will need to contact you before any treatments can be performed.)

Area CodePhone Number
Pet's Name
Why are we seeing your cat today?

Other
Would your cat benefit from pre-visit medication to reduce anxiety to facilitate a lower stress visit?
If yes, please explain:
If your cat is being seen today for an injury or illness, have they been seen by another veterinarian for this issue? If so, when and where?
If you have a health concern, please describe below. How long has it been going on? Is it improving, getting worse, staying the same? If you have no concerns, write "none."
If no health concerns, please type "none".

Is there any additional information that would be helpful to us (more details about a previous answers, behavioral concerns, helpful hints on handling your cat, particular triggers your pet may have, etc)?
If none, type N/A
If your cat has been seen at another facility that we do not already have records from, please provide the name(s) and city/state of those clinics so that we can request their records. This will ensure that we have all the information needed to appropriately care for your cat.
If none, type N/A
In the event that your cat should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of your cat's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Although we may not anticipate any issues, because you will not be onsite for any/all treatment, please indicate your wishes below in the event of any cardiac and/or respiratory arrest while your cat is with us today.
I approve use of photos or videos of my cat for educational or social media purposes when appropriate.
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. By entering my name below, I certify that I am over eighteen years of age. I understand that as part of The Feline Medical Center's desire to keep my pet's visits as fear free as possible, if my pet shows signs of elevated fear and/or anxiety, they may receive an anti-anxiety and/or sedating medication at the discretion of the doctor unless I specifically request otherwise. There may be an additional cost for this service. I authorize and direct the veterinarian and designated staff of The Feline Medical Center to receive, treat, medicate, and perform diagnostic and/or therapeutic procedures as discussed and provided in the estimate. If no estimate has been provided, I authorize a comprehensive exam (cost is $108.00) to be performed in order to generate an estimate. The purpose of the hospitalization and the proposed treatment plan have been clearly explained to me. I understand that no guarantee of successful treatment outcome can be given and that the patient's condition may improve or decline during the period of hospitalization despite appropriate medical care and monitoring. I understand that unexpected reactions to medications can occur. If I have any questions about the potential risks, I have discussed them with the staff before hospitalizing my pet. If further care is needed after business hours (Monday 7:30am-7:00pm; Tuesday-Friday 7:30am-6:00pm) or on holidays, I understand that transfer of care to the nearest emergency animal hospital is recommended. Patient transport to and from the emergency clinic as well as any additional cost incurred during the stay are my responsibility. In the event that transfer to the emergency clinic is not a possibility, I understand that the patient will only receive intermittent monitoring and that unexpected and serious complications may develop during this period. I agree to pay in full at time of service for all services performed, including those deemed necessary for medical/surgical complications or otherwise unexpected circumstances. I also understand that appointments arriving 10-15 minutes late will incur a $25 late fee. Appointments arriving 15+ minutes late will be asked to reschedule if the veterinarian’s schedule cannot accommodate. If you would like to wait, we can work you into the schedule for an additional fee. If you elect to wait, please understand that wait times may be unpredictable and that priority is given to those patients that arrive on time. Late Arrival Policy: Any appointment arriving 10-15 minutes late will be charged a $25 late fee. Appointments arriving 15+ minutes late will be asked to reschedule if the veterinarian’s schedule cannot accommodate. If you would like to wait, we can work you into the schedule for an additional fee. If you elect to wait, please understand that wait times may be unpredictable and that priority is given to those patients that arrive on time. No show appointments or cancellations less than 6 hours prior to your appointment time will incur a fee of $40.00. Frequent no-shows will result in having to pre-pay for your visit in advance. I have read and understand this authorization and hereby accept and agree to the terms of the consent for hospitalization and/or treatment.
Type your full name to agree to the above statements.
Signature
Date

MonthDayYear
Date
Name

First NameLast Name
Appointment
Type a question
Should be Empty:

General History Form

Curbside appointments are still available on request.