Pre Echocardiogram Questionnaire

Pre Echocardiogram Questionnaire

Please fill out this form in entirety and submit PRIOR to your pet's appointment to ensure we can provide your pet with the best possible care.
Date

MonthDayYear
Date
Your Name*

First NameLast Name
Pet's Name*

First NameLast Name
Best number to reach you while your pet is here?*
Format: (000) 000-0000.
It is imperative that we be able to reach you in a timely manner while your pet is with us today. Please list your cell phone above and be readily available to talk.
What is your pet's current diet? ?
PLEASE LIST ALL BRANDS OF FOOD, AMOUNT FED AND FREQUENCY.
Please list ALL of your pet's current medications and/or supplements and dosages and frequency given:
EXAMPLE: VETMEDIN 1.25MG, ONE TABLET TWICE DAILY.
Is your pet coughing?

YesNo
If your pet is coughing, is the cough new or worsening since last visit?

YesNo
Are you monitoring your pet's resting respiratory rate?

YesNo
If you are monitoring your pet's respiratory rate, what is their current resting rate?
Breaths per minute.
Any changes in energy while on walks?

YesNo
If there are changes in energy, please explain.
Less active, lays down, unable to walk as far, etc.
Any other information or health changes?
Please explain.
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Orange Canyon Pet Clinic. I authorize the use of medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).*
Initial
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300).Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
I acknowledge my choice regarding resuscitation for my pet as noted above.
Initial
Signature*
Appointment Deposit Policy

All clients are required to make a $250.00 deposit when booking their appointment. Our goal is to provide quality health care to all our patients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our providers, but our other patients as well. If cancellation is necessary, we require that you call at least 24 hours in advance. A cancellation is considered late when the appointment is cancelled less than 24 hours before the scheduled appointed time. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.
I acknowledge the policy on Deposits and Canceled Appointments
Initial
Should be Empty:

Pre Echocardiogram Questionnaire

Authorizations