St. Francis- Drop Off Exam Sick Pet Medical History Form

Drop Off Exam- Sick Pet Medical History Form
Name*

First NameLast Name
Email*
example@example.com
Phone number where you can be reached while your pet is in our care:*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Appointment*

MonthDayYear
Date
Drop Off Exam Protocol

Because we currently have COVID-19 safety protocols in place, we are not allowing clients into our building for drop off exams. When you arrive in our parking lot, please call the number on the sign in front of you for Appointments (763-280-4031). This number calls our concierge phone. If a staff member is available to answer the phone, they will perform a brief check in. If all of our staff is busy and you reach our voicemail, please leave a message and we will call you back as soon as possible. If you leave a message and have been waiting for more than 15 minutes, please call back (unfortunately, despite our best efforts, technology sometimes fails us!).

Once you are checked in, an assistant will come to your car to bring your pet into the clinic, and then you are free to leave. The doctor or a member of your pet's care team will call you once your pet's exam has been performed to inform you of the findings and to discuss next steps for your pet. Drop off exams are performed in between our scheduled exams and procedures. While this allows us to see more pets for urgent care and same-day needs, it does mean that the timing of these exams may be difficult to predict. Pets who are severely ill will be prioritized over pets who are medically stable. Pets being seen for drop off exams may need to be with us until the end of our business day at 6 pm. If you have any specific scheduling needs with regards to timing for pick-up, please let us know as soon as possible and we will do our best to accomodate those needs.
Pet's Name*
Gastrointestinal upset (vomiting, diarrhea, poor appetite)Respiratory disease (coughing, sneezing, difficulty breathing)Urinary abnormalities (frequent urination, painful urination, blood in urine, straining to urinate)Skin or ear concerns (head shaking, itching/chewing at skin, scooting)Wound (bite wound, laceration, abscess)LimpingPainful (tense belly, yelping when touched)Eye concerns (eye discharge, red eye, squinting)Unsure (not acting like themselves, but no specific symptoms)Other
General Medical History
When did you first notice symptoms?*
What specific symptoms has {petsName} been showing?*
No changesBetterWorseI don't know
NoI don't knowYes (please explain)
NoI don't knowYes (please explain)
NoI don't knowYes (please explain)
List all medications and supplements {petsName} is currently taking.
Gastrointestinal Upset
NoI don't knowYes (please explain)
NoI don't knowYes (please explain)
Respiratory Disease
NoI don't knowYes (please explain the type of exposure)
Urinary Abnormalities
NoI don't knowYes (please describe)
NoYesI don't know
Skin/Ear Concerns
NoI don't knowYes (please describe)
NoYes (please describe what you have used and when)
NoYesI don't know
NoYesI don't know
Limping
Left frontRight frontLeft rearRight rearI can't tell
NoYes (please explain)
Wound or Injury
NoYes (please provide details)
Eye Concerns
Only the left eyeOnly the right eyeBoth eyesOther (please explain)
NoYes (please describe)
NoYes
Consent To Proceed with Diagnostic Testing and/or Treatments
I understand that the veterinarian may recommend diagnostic tests such as bloodwork or x-rays to determine the cause of my pet's illness, as well as treatments such as fluid therapy or medication. Following my pet's exam ($99.25), I authorize up to enter dollar amount* in diagnostic testing and/or treatments prior to needing additional consent. (If you enter $0, someone from your pet's care team will call you prior to any additional testing or treatments).
Consent for CPR or DNR
For every patient in our care, we need to know, in advance, what your wishes are if your pet stops breathing and/or their heart stops beating. We will make every attempt to contact you right away should your pet require resuscitative efforts. Additional expenses are incurred with the attempt to resuscitate the patient. Please review and select one option below.

Cardiopulmonary Resuscitation (CPR): All resuscitative efforts are to be attempted to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR) , I request that the doctor(s) may pursue such medical care indicated above. I understand that this is a cost in ADDITION to any estimate and agree to pay this fee. The cost of full CPR is typically an additional $300 - $500 or more. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a speciality facility following resuscitation.

Do Not Attempt Resuscitation (DNR): No cardiopulmonary resuscitation (CPR) efforts, only the administration of medication to help ease my pet's passing.
Cardiopulmonary resuscitation (CPR)Do Not Attempt Resuscitation (DNR)
Signature*

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Today's Date*

MonthDayYear
Date
Should be Empty:

Drop Off Exam- Sick Pet Medical History Form

General Medical History

Gastrointestinal Upset

Respiratory Disease

Urinary Abnormalities

Skin/Ear Concerns

Limping

Wound or Injury

Eye Concerns

Consent To Proceed with Diagnostic Testing and/or Treatments

Consent for CPR or DNR