Exam Request and Pet History Form

What is the reason for requesting an exam?*

Notice: In order to receive dental surgery from our clinic, we require your pet to be spayed or neutered either before or during the dental surgery.

Have you received an estimate for the same service from your primary vet clinic?

YesNo

Please let us know why you have chosen not to move forward with the dental surgery from your primary vet clinic.

I could afford the service from my primary vet clinic, but it's more than I want to pay.I cannot afford the service from my primary vet clinic.Other

Have we provided vet care to your any of your pets within the last 3 years?

NoYes

Please describe your pet's symptoms.

If your pet is currently bleeding, in obvious pain, or has been involved in some kind of accident (stepped on, fell from a high place, etc.), your pet may be experiencing a medical emergency and needs urgent attention.

In cases of an emergency, please take your pet to an urgent care clinic.

In Anchorage, the urgent care clinics are:

Midnight Sun Animal Hospital on Tudor Road
Pet ER on the corner of Lake Otis Pkwy & Dowling Road

In the Mat-Su Valley please go to Tier 1 on the frontage road of the Parks Hwy heading into Wasilla.

Is your pet being treated for seizures, or has s/he ever had seizures?*

NoYes

Is your cat exhibiting signs of straining to urinate?*

NoYes

Does your cat go outside?*

NoYes

Does your dog interact with dogs outside of its household?*

NoYes

Has your pet been seen by another veterinarian for the same issue that brings you here today?*

NoYes

Please tell us where and when your pet was seen.

List any prescription or over-the-counter medications, diets, supplements, vitamins, heartworm/flea/tick meds, etc. that your pet has taken in the last sixty days.*

What food do you feed your pet?*

How much and how often do you feed your pet?*

Is your pet eating more/less than is typical?*

NoYes

Describe the change in your pet's eating habits.

Is your pet drinking more/less water than is typical?*

NoYes

Describe the changes in your pet's water consumption.

Has your pet been vomiting?*

NoYes

How long and how often has your pet been vomiting?*

Describe your pet's recent urination habits. Have they been urinating more or less than they used to? Has the color or odor changed? Are they urinating in any new/strange places?*

Describe your pet's recent bowel movements. Are they normal? Is there any diarrhea/blood/abnormal appearance? Has the frequency changed?*

Is your pet coughing or sneezing?*

NoYes

Has your pet ever bitten a person such that their skin was broken?*

NoYes

Please describe the incident(s).

Do you have any other concerns about your pet that have not been addressed in the questions above?*

NoYes

List your additional concerns or questions.

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Exam Request and Pet History Form

Exam Request and Pet History Form

Pet Information

Health and History

Exam Fee