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Feline (Cat) Pre Exam History Form
1
Owner/Responsible Person
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First Name
Last Name
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2
Patient Name
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3
Best Contact Number
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4
How would you like to be contacted?
Text
Phone Call
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5
Has your pet ever had ANY adverse (allergic) reaction to any medications, vaccinations, or other procedure?
*
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YES
NO
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6
Where does your pet spend most of his/her time?
*
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(Please choose one)
Strictly Indoor Only
Mostly Indoor; occasionally outside access
Indoor/Outdoor (free roam outside)
Strictly Outdoor
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7
Please check the following services you would like updated with today's Annual Wellness appointment.
*
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All Annual Wellness visits require a Comprehensive Wellness Exam.
(Please check all that apply)
FVRCP Vaccine
Rabies Vaccine
Leukemia Vaccine
Fecal/Intestinal Parasite Screen
FeLV/FIV Combo Test
Annual Wellness Bloodwork
I am unsure and would like to discuss recommendations with a staff member
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8
Additional Services:
*
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(Please check all that apply)
Nail Trim
Ear Cleaning
Sanitary Trim
Toothbrushing
Laser Therapy
Solensia
None
Other
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9
Lab work results can take up to 48 hours to receive. Histopath or Cultures can take up to 14 days to receive. How would you like to be contacted once we receive your pet's results?
*
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Text
Phone Call
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10
Have you noticed any of the following problems/concerns with your pet:
*
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(Please check all that apply)
Increase in appetite
Decrease in appetite
Increase in drinking
Decrease in drinking
Shaking Head
Bad Breath
Weight Loss
Weight Gain
Vomiting/Gagging
Diarrhea
Increase in Urination
Decrease in Urination
Skin Masses/Bumps
Hair Loss
Excessive Sneezing
Inappropriate Urination/Defecation (Going to the bathroom outside of the litter box)
Behavioral Problems
No Concerns
Other
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11
What brand of food do you feed your pet?
*
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12
How much do you feed your pet?
*
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Free Fed (food is always offered/whenever hungry
Measured amount
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13
If measured, please specify how much and how often below:
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14
Do you give your pet heartworm and/or flea/tick prevention regularly?
*
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Yes
Yes, and I would like a refill today
No
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15
If yes, please specify what brand of prevention you give your pet.
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16
Do you have other pets?
*
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YES
NO
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17
Do you have any additional questions/concerns that you would you like to discuss at your appointment?
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18
Social Media/Photo Permission: Do we have your permission to post photos/videos of your pet online?
*
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YES
NO
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19
Payment Authorization: I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of service unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs and collection agency fees. I hereby authorize Monroe Veterinary Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reaction occur.
*
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I agree
I disagree
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20
Signature
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21
Date
*
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-
Date
Year
Month
Day
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