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.
We ask that you please do not enter the building for any reason if you are running a fever or showing any respiratory symptoms for the safety of our clients and staff. Curbside appointments are still available on request.
Owner's Name *

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

Yes No
New Mailing Address *

Street Address

Street Address Line 2

City State

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 Code Phone Number
Pet's Name *
Why are we seeing your cat today? *

General wellness or booster exam (with or without vaccines) Rechecking a health concern that has been previously diagnosed I have a new health concern (please describe below)
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 agree to CPR being performed in case of arrest. I elect a “Do Not Resuscitate” status in case of arrest .
I approve use of photos or videos of my cat for educational or social media purposes when appropriate.

Yes No
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 $78.95) 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 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 *

Clear
Date *

Month Day Year
Date
Name

First Name Last Name
Appointment
Should be Empty:

General History Form

We ask that you please do not enter the building for any reason if you are running a fever or showing any respiratory symptoms for the safety of our clients and staff. Curbside appointments are still available on request.