History | Veterinary Clinic Timeline

Primary contact for medical questions (name + phone number):*

Person to contact for pick up (name + phone number) or same as above:*

What brings your pet in today?*

How long have you noticed the symptoms going on?*

Please check all that are occurring:*

If diarrhea is present, how often a day? Is there straining? Any red blood? Any black coloration?

Is there limping? If so, which leg(s)?

Has your pet been to another vet, ER, or specialist? If so, which one so we can get records?*

Current medications?*

Drug name, dose, how often it is given, last time/date administered; please include flea/tick/heartworm preventative and any supplements (ex: amlodipine 2.5mg tab - half tab once daily, last received this morning at 8am)

Diet? In the event that your pet is advised to stay in the hospital after their appointment, what type of food do they eat, how much, and how often?

If blood work (approximately $250) and/or radiographs (approximately $300) are deemed advisable or necessary, I understand the associated costs and authorize these diagnostics to be performed:*

Yes
No

I hereby acknowledge that I have full authority of this pet and direct Chris Reagh DVM, Andrea Mears DVM, Judi Vinch DVM, Staci Schroeder DVM, Kelly Zilli DVM, or Chantel Raghu DVM DACVIM to perform the procedure and additional diagnostics and/or treatment procedure deemed advisable or necessary. I understand there may be risk involved in these procedures. Be assured that the health of your pet is our highest concern and we will do everything possible to maintain the health. The provided Care Plan & Estimate of Cost only approximates the cost of the visit. It does not include any treatments that may be deemed necessary upon examination and commencement of the included treatments. The client (you) will be responsible for all fees incurred during this visit included or not on the Care Plan. If fleas and/or parasites are found during the exam, there will be an additional charge for treatment. Your signature below indicates that you have reviewed and agree to the terms above.*

I agree.

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History Form