Patient Drop Off Form
Owner's First and Last Name
*
Owners Name
Phone #:
*
Format: (000) 000-0000.
Secondary Number (in case we can't reach the primary #):
Format: (000) 000-0000.
Owner Birthdate (required for dispensing class II-IV medications):
*
Patient Name
*
Date of Appointment:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for visit (please be specific):
*
Select 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 circled items, please describe:
How much time does your cat spend outdoors (including screened in areas. If indoor only, put that):
*
What BRAND and AMOUNT of WET food does your cat eat?:
*
Dry Brand/Amount:
*
Treats/Table food (if none, put n/a):
*
What kind of Flea/Tick/Heartworm prevention do you use?
Date Last Applied:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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. Choose 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.
BEST PHONE NUMBER TO REACH FOR SEDATION AUTHORIZATION
FOR YEARLY WELLNESS EXAMS: SELECT ONE OPTION
*
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. CIRCLE APPROVED DIAGN0STICS IF DEEMED NECESSARY
*
BLOODWORK
FECAL
URINALYSIS
RADIOGRAPH
EAR CYTOLOGY
SKIN SCRAPING
NONE: CONTACT ME BEFORE PERFORMING DIAGNOSTICS
Client Signature:
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