Patient Drop Off Form
Owner Name:
*
Phone #:
*
Format: (000) 000-0000.
Secondary Number (in case we can't reach the primary #):
Owner Birthdate (required for dispensing class II-IV medications):
*
Patient Name:
*
Date of Drop Off:
*
-
Month
-
Day
Year
Date
Reason for visit (please be specific):
*
Check any symptoms your cat is experiencing:
Vomiting
Diarrhea
Coughing
Sneezing
Skin Issues
Eye Issues
Change to Appetite
Change to water intake
Litterbox problems
Behavior changes
For any selected symptoms, please describe:
How much time does your cat spend outdoors (including screened in areas):
*
What BRAND and AMOUNT of WET food does your cat eat? If none, put N/A
*
What BRAND and AMOUNT of DRY food does your cat eat? If none, put N/A
*
Treats/Table food frequency:
What kind of Flea/Tick/Heartworm prevention do you use?
What Medications/Supplements (and doses) do you give your cat? If none, put N/A
*
Would you like your cat's nails trimmed for a nominal fee?
*
YES
NO
We will always try to do exams and treatments awake but occasionally sedation IS necessary. Select ONE of the following:
*
I authorize sedation for my cat if necessary. I understand if I cannot be reached when my cat is sleeping, the doctor will proceed with required treatments for the presenting problem.
DO NOT sedate my cat prior to contacting me.
FOR YEARLY WELLNESS EXAMS ONLY
I authorize yearly screening lab work and/or blood pressure check for well cat exams.
Contact me prior to performing ANY diagnostics.
FOR SICK CAT EXAMS: We often recommend diagnostics to figure out what is wrong with your cat and guide treatment. Please select approved diagnostics
BLOODWORK
FECAL
URINALYSIS
RADIOGRAPH
EAR CYTOLOGY
SKIN SCRAPING
NONE: CONTACT ME BEFORE PERFORMING DIAGNOSTICS
Client Signature:
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