Patient History Patient History 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: Vomiting Diarrhea Constipation Increased Appetite Decreased Appetite Abnormal Urination Increased Drinking Decreased Drinking Lethargy Lameness Change in Behavior Crying or Whimpering Excessive Panting Coughing, Wheezing, Choking, or Gagging Sneezing Tremors or Seizures 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: Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.