Medical History
Convenient Drop off Appointment Release
Full Name
*
First Name
Last Name
Pet's Name
*
Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
Please ensure that you are available by phone until your pet is released back into your care.
Please enter Diet and Feeding information.
*
Check the conditions that apply to your pet.
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Coughing
Sneezing
Vomiting
Diarrhea
Eye Discharge
Dirty/Itchy Ears
Nasal Discharge
Limping
Skin Issue
New or changed lump
No concerns
Lethargy
Lack of Appetite
Other
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Please Select
Yes
No
Check the symptoms that your pet is currently experiencing:
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Not eating
Trouble breathing
Trouble Defecating
Trouble Urinating
Weight gain
Weight loss
Change in behavior
Change in activity level
No concerns
Other
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please Select
Yes
No
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking, including Heartworm Prevention and Flea and Tick prevention.
Has your pet ever had a reaction to vaccinations?
*
Yes
No
Not Sure
Please indicate what preventatives or medications you need a refill of:
Heartworm Prevention/ Parasiticide
Flea and Tick Prevention
Other
Which preventative care procedures have your approval prior to the appointment? (Select all or none that apply)
*
All vaccines due
Intestinal Parasite (Fecal) Lab test
Heartworm/Tick Parasitology (Blood) test
Annual Bloodwork
Urinalysis
None, please consult me on each service before I consent
Other
Are there any other issues/concerns that you would like to discuss at your appointment?
I hereby authorize Buffalo Mountain Animal Hospital to examine, prescribe for, or treat my pets in their care. I assume financial responsibility for all charges incurred for services or medication and understand that payment is due in full at the time of the appointment.
Please type in your initials
Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are not able to arrive on time, we may need to reschedule your appointment.
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