Drop Off Exam- Medical History and Consent Form
Client Name
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First Name
Last Name
Pet Name
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Date of scheduled drop-off exam
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Month
-
Day
Year
Date
Phone Number
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-
Area Code
Phone Number
What is the primary concern for your pet's drop off exam?
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Coughing/Sneezing
Ear Problem
Eye Problem
Lameness (Limping)
Lump
Progress Exam to follow up on a recent medical issue
Skin Problem
Urinary Problem
Vomiting/Diarrhea
How is your pet's appetite?
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Normal
Increased
Decreased
Will not accept any food, including treats
How is your pet's thirst level?
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Normal
Increased
Decreased
Not drinking any water at all
How is your pet's energy level?
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Normal
Increased
Decreased
How are your pet's urination habits?
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Normal
Increased
Decreased
How are your pet's defecation habits?
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Normal
Increased
Decreased
When did your pet last eat?
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Please list all medications and supplements your pet is currently taking.
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Has your pet been treated an another veterinary clinic in the last 12 months? If yes, please list the name of the clinic.
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Coughing/Sneezing Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
What problem is your pet experiencing?
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Sneezing
Coughing
Both Coughing and Sneezing
How would you describe the severity of your pet's symptoms?
Mild
Moderate
Severe
When did the problem start?
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Has your pet recently visited a boarding/grooming facility and/or dog park?
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Yes
No
Have you noticed any mucus discharge from the nose? If yes, please describe.
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Have you noticed any weight-loss?
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Yes
No
Any additional notes for our doctor regarding your pet's coughing/sneezing
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to perform the following diagnostic procedures:
Chest X-ray- $161
Blood Testing- $214 (includes CBC, Chemistry and Electrolyte Panel)
Please call me before performing any diagnostic procedures
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Ear Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
Which ear is affected?
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Right
Left
Both
When did your pet's ear problem start?
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Has your pet had any recent exposure to water? (swimming, bath, etc.)
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Yes
No
Have you noticed any odor coming from the affected ear?
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Yes
No
Have you seen any discharge in the affected ear?
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Yes
No
Is your pet's affected ear painful?
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Yes
No
Where does your pet spend most of their time?
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Indoors
Outdoors
Has your pet experienced any vomiting or diarrhea alongside this ear issue?
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Neither
Vomiting
Diarrhea
Both
Have you noticed your pet tilting their head to one side since the start of the ear issue?
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Yes
No
Have you used any over-the-counter ear cleaners and/or treatments at home? If yes, please list the name of the product(s) you have used.
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Does your pet have a history of prior ear problems? If yes, please describe.
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Any additional notes for the doctor regarding your pet's ear issue?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to perform the following diagnostic procedures:
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Ear Discharge Analysis- $56 (to identify the cause of the ear infection)
Ear Cleaning- $53
Please call me before performing any diagnostic procedures
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Eye Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
Which eye is affected?
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Right
Left
Both
When did your pet's eye problem start?
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Have you noticed any discharge from the affected eye?
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Yes
No
Is your pet squinting the affected eye?
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Yes
No
Has your pet recently been exposed to any household chemicals (shampoo, cleaning products, etc)? If yes, please list the name of the product.
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Where does your pet spend the majority of their time?
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Indoors
Outdoors
Are there any other pets in your home?
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Yes
No
Has your pet experienced any vomiting or diarrhea alongside this eye issue?
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Neither
Vomiting
Diarrhea
Both
Does your pet have any history of prior eye problems? If yes, please describe.
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Any additional notes for our doctor regarding your pet's eye problem?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to perform the following diagnostic procedures:
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Fluorescein Eye Stain- $44 (Helps identify injuries on the surface of the eye)
Schirmer Tear Test- $38 (Evaluates your pet's tear production)
Please call me before performing any diagnostic procedures
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Lameness Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
Which leg is affected?
Front Right
Front Left
Hind Right
Hind Left
When did the lameness start?
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How would you describe your pet's pain level?
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Mild
Moderate
Severe
Not painful at all
Does your pet have difficulty with any of the following? (Check all that apply)
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Walking
Running
Stairs
Jumping
Climbing
How often does your pet get regular exercise (walks, runs, fetch, etc.)?
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Daily
Weekly
Monthly
Does your pet have a history of prior injury, trauma, or surgery on this limb? If yes, please describe.
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Any additional notes to the doctor regarding your pet's lameness?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic to perform the following diagnostic procedures:
*
X-rays- $161
Please call me before performing any diagnostic procedures
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Lump Exam Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
Please describe where the lump is located on your pet's body.
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When did you first notice this lump?
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How much does your pet seem to be bothered by this lump?
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Not at all
Mildly
Moderately
Severely
Has the lump changed since you first noticed it? If yes, please describe the changes.
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Any additional notes for our doctor regarding the lump?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to perform the following diagnostic procedures:
*
Cytology- $66 (Microscopic analysis of cells collected from the lump)
Blood Testing- $214 (includes CBC, Chemistry and Electrolyte Panel)
X-Rays- $161
Please call me before performing any diagnostic procedures
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Progress Exam Questionnaire
What are we following up on at this drop-off appointment?
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Bandage Change
Coughing/Sneezing
Ear issue
Eye issue
Lab Work (blood/urine/fecal testing)
Lameness
Lump
Skin issue
Surgery
Urinary issue
Vomiting/Diarrhea
Have you noticed any change in your pet's condition since your last visit?
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Better
Worse
No change
Does your pet have any medications leftover?
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No, my pet has completed a full course of medications.
No, my pet has run out of medications, and needs a refill.
Yes, my pet is still taking medications as prescribed.
Yes, we discontinued use of one or more medications**
Have you noticed any new problems/symptoms since your pets last visit? If yes, please describe.
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Any additional notes to the doctor regarding your pet's progress exam?
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Skin Issue Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
Which skin issue is your pet experiencing? (Check all that apply)
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Itching
Rash
Redness
Pustules
Sores
When did you first notice your pet's skin problem?
Which areas of your pet's body are affected? (Check all that apply)
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Face
Ears
Abdomen
Front Legs/Paws
Back Legs/Paws
Lower Back/Tail
All over
Is your pet experiencing any hair loss?
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Yes
No
Does your pet scratch/lick/chew/bite itself?
Yes
No
How severe is your pet's itching?
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Mild
Moderate
Severe
Not itchy at all
Which food do you feed your pet?
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Please enter brand name and specific diet. Example: Purina Pro Plan- Adult Complete Essentials
Where does your pet spend most of their time?
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Indoors
Outdoors
Has your pet ever had a similar issue in the past? If yes, please explain.
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Any additional notes for the doctor regarding your pet's skin issue?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic Permission to perform the following diagnostics:
*
Skin Scrape/Microscopic Analysis- $53
Thyroid Test- $64
Blood Testing ($214- includes CBC, Chemistry and Electrolyte Panel)
Please call me before performing any diagnostic procedures
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Next
Urinary Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
When did you first notice your pet's urinary problem?
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Is your pet urinating inappropriately, such as in the house, or outside of their litterbox?
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Yes
No
Is your pet experiencing frequent urination?
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Yes
No
Have you noticed any wet spots where your pet has been laying/sleeping?
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Yes
No
Have you noticed any blood in your pet's urine?
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Yes
No
Have you noticed any changes in your pet's mental status?
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Yes
No
Is your pet experiencing any vomiting or diarrhea?
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Neither
Vomiting
Diarrhea
Both
Have you noticed any recent weight loss in your pet?
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Yes
No
Is your pet up to date on vaccinations?
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Yes
No
I'm unsure
Has your pet recently been exposed to any toxins? If yes, please enter the name of the toxin.
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Example: Yes- Antifreeze
Has your pet had any recent illnesses, injuries or trauma? If yes, please explain.
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Has your pet had any urinary issues in the past? If yes, please explain.
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Any additional notes for the doctor regarding your pet's urinary problem?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to run the following diagnostics:
*
Urinalysis- $72
Cystocentesis- $39 (Procedure to collect a urine sample directly from the bladder)
Blood Testing ($214- includes CBC, Chemistry and Electrolyte Panel)
Please call me before performing any diagnostic procedures
Back
Next
Vomiting/Diarrhea Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
What problem is your pet experiencing?
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Vomiting
Diarrhea
Both
When did your pet start experiencing vomiting and/or diarrhea?
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How frequently is your pet vomiting and/or having diarrhea?
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Are there whole pieces of food in your pet's vomit?
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Yes
No
My pet is not vomiting
Have you noticed any blood in your pet's vomit?
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Yes
No
My pet is not vomiting
Are there large volumes of vomit?
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Yes
No
My pet is not vomiting
Have you noticed that any of your pets toys (or any household items) have gone missing?
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Yes
No
Any recent exposure to household chemicals or other possible toxins? If yes, please provide the name of the chemical/product.
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How would you describe your pet's stool?
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Watery/Runny
Soft
Solid
Have you noticed any blood in your pet's stool?
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Yes
No
Have you noticed any mucus in your pet's stool?
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Yes
No
Is your pet current on vaccinations?
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Yes
No
I'm unsure
Has your pet had any recent illnesses, injuries, or trauma? If yes, please explain.
*
Any additional notes for the doctor regarding your pet's vomiting/diarrhea?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to run the following diagnostics:
*
Abdominal X-rays $161
Abdominal Ultrasound $221
Blood Tests $214 (Includes CBC, Chemistry and Electrolyte Panel)
Please call me before performing any diagnostic procedures
Back
Next
General Medical Questionnaire
Please take the time to answer the following questions thoroughly, and completely. This information is vital to our doctor's diagnostic process.
What problem is your pet experiencing?
*
When did the problem start?
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Has the problem changed since you first noticed it?
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No change
Better
Worse
Has your pet ever had a similar problem in the past? If yes, please explain.
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What is your pet's current diet and feeding schedule?
*
When was your pet last vaccinated?
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Have you noticed any weight loss in your pet?
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Yes
No
Has your pet had any recent exposure to household chemicals or other toxins? If yes, please list the name of the product.
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Any additional notes to the doctor regarding the problem your pet is experiencing?
Diagnostic Procedures
In addition to a physical examination of your pet, our medical team may need to perform some diagnostic procedures in order thoroughly evaluate your pet's overall health and make an accurate diagnosis.
I give Broadmoor East Veterinary Clinic permission to run the following diagnostics:
*
Abdominal X-rays $161
Blood Tests $214 (Includes CBC, Chemistry and Electrolyte Panel)
Please call me before performing any diagnostic procedures
Back
Next
Sedation
Some procedures (such as x-rays, ultrasound, cystocentesis, etc.) may require the use of sedation in order to complete them safely, and reduce patient stress and discomfort. If sedation is recommended by BEVC, I authorize the staff of BEVC to sedate my pet, understanding that risk is inherent with sedation, and that results cannot be guaranteed. I further request and authorize emergency treatment should it become necessary while under the care of the of BEVC.
Do you authorize the use of sedation if the doctor deems it necessary for the safety and comfort of your pet?
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Yes, I authorize use of sedation and agree to the above statements.
Please call me before sedating my pet for diagnostic procedures.
Additional Procedures
For your convenience, we can perform the following procedures while your pet is in-clinic for their drop-off exam. *Please note that, if you are requesting vaccines, this will be done at the doctor's discretion, depending on their findings on your pet's exam. If your pet is ill, vaccinations may not be given until your pet has recovered from their illness.
I request the following optional procedures to be performed while my pet is in the care of Broadmoor East Veterinary Clinic for their drop-off exam.
Nail Trim $23
Anal Gland Expression $26
Implant Microchip $53
Rabies Vaccine $37
Distemper Vaccine $46
Bordetella Vaccine $42
Leptospirosis Vaccine $39
Feline Leukemia Vaccine $41
Drop Off Exam Consent
By signing below, I authorize Broadmoor East Veterinary Clinic to examine, test, and treat my pet based upon the symptoms/injuries described above. If diagnostic testing/procedures and/or sedation are declined, I realize that the doctors may not be able to make a diagnosis and/or treat my pet today. I understand that the doctor will discuss their findings with me, in person, upon my pet's discharge from the hospital. I agree to pay in full at the time of my pet's discharge from the hospital.
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I have read, understand and agree to the above statement
Signature
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