GP & Surgery - Current Patient Appt Request - Oxford Veterinary Hospital

Your First and Last Name:*

Your Pet's Name (Please, fill out a separate form for each pet):*

Email Address:*

How would you like us to contact you:*

Phone Call
Text Message
Email

What is the Primary Reason for your pet's visit?*

If your pet is experiencing any of the following symptoms, please check all that apply:

If you checked any of the symptoms above, please provide more detail (how long, frequency, etc).:

If your pet is experiencing any of the following symptoms, please check all that apply:

Shaking head or Ear odor
Scooting rear
Hair Loss
Rash
Itching or Scratching
Lumps or Bumps
Unusual Discharge

If you checked any of the symptoms above, please provide more detail (how long, frequency, location, etc).:

Please list all medications your pet is currently receiving. Please include all prescription and over the counter medications:

What is your pet's current diet? Brand and type of food? Amount of treats given a day?:

Urgent Blood-work: If your pet is being brought in for vomiting, diarrhea, lethargy, decreased eating, decreased drinking, or on another urgent basis; running a blood profile in clinic will be an important part of the diagnostic process. Please indicate below whether we can proceed with blood-work:

YES
NO
Call with cost prior to any diagnostic testing being performed
Not Applicable, Patient is in for wellness visit and not exhibiting any of the above symptoms.

Routine Lab-work: If your pet is coming in for their annual visit please check the lab-work:

Canine: Adult wellness with intestinal parasite screen and heartworm testing: (Recommended for patients 1-6 years old)
Canine: Senior wellness with urinalysis, T4, intestinal parasite screen, and heartworm test: (Recommended for patients 6+ years old)
Canine: Intestinal parasite screen and heartworm test ONLY:
Feline: Adult wellness with intestinal parasite screen (Recommended for patients 1-6 years old)
Feline: Senior wellness with urinalysis, T4, and intestinal parasite screen (Recommended for patients 6+ years old)
Call before proceeding with blood-work

If your pet is being seen for lameness, coughing, difficultly breathing, vomiting, abnormal urination, constipation or other Gastrointestinal issue x-rays will be an important part of the diagnostic process. Please indicate below whether we can proceed with x-rays:

YES
NO
Call before proceeding with x-rays
Not Applicable, Patient is in for wellness visit and not exhibiting any of the above symptoms.

In the event further diagnostics and/or treatments are needed, please indicate how you would like us to proceed:

Perform any additional diagnostics and/or treatments
Call or text me first. If you cannot reach me, you may proceed with any diagnostics and/or treatments deemed necessary.
Do nothing else unless you contact me

My typed name here is my signature:

Date:

GP & Surgery – Current Patient Appt Request

General Practice & Surgery - Current Patient Appointment Request

After the online form is submitted, we will reach out to you within one business day to schedule the appointment.