Owner Full Name*

First Last

Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?*

Yes
No

Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough or difficulty breathing?*

Yes
No

Pet Name*

Breed*

Species*

Sex*

Emergency contact number for today*

How would you like us to contact you today?*

Phone
Text
Video

Would you like us to make this your primary contact number?*

Yes
No

Date and time of appointment*

Make, Model and Color of car you will be driving*

My pet is being seen today for the following reason/treatment:*

Wellness visit
Sick visit

Reason:*

Duration of problem?*

Location of problem?*

Is your pet currently on any medication (including heartworm and flea prevention and/or supplements?)*

Yes
No

If yes, name of medication(s), current dosage, quantity and when last given*

Do you need refills of any of your medications?*

Yes
No

If yes, please list them, include heartworm, flea and tick prevention and how many months of each you need.*

What do you feed your pet? How much? How often?*

Was food offered today?*

Yes
No

When did your pet last eat?*

Do you need any refills of prescription pet food?*

Yes
No

If yes, list name of food, size and quantity.*

Has your pet shown any sign of the following? (mark all that apply)*

How long has your pet been vomiting?*

How long has your pet had diarrhea?*

How long has your pet been lathargic?*

How long has your pet had no appetite?*

How long has your pet been coughing?*

How long has your pet been sneezing?*

How long has your pet been urinating more or less than usual?*

How long has your pet been drinking more or less than usual?*

How long has your pet been shaking their head?*

How long has your pet been scratching?*

How long has your pet been having seizures?*

How much weight has been gained or lost?*

Which leg? How long?*

How long has your pet been scooting?*

Location of the unusual lumps or bumps?*

Additional Information:*

After the initial examination, we should*

Perform whatever servcies the doctor deems necessary until I may be reached.
Call first to discuss treatment and tests.

I certify I am the owner (or agent for the owner) of the described animal(s) and have the authority to execute this consent. I hereby consent to and authorize the performance of the above operation(s) or procedure(s), and/or other procedure(s) or operation(s) that are deemed necessary and desirable in the exercise of the veterinarian's professional judgment, including use of appropriate anesthetics, and agree to pay any and all additional charges incurred. For example, during spay and neutering services, there is an additional charge if a female is pregnant or the pet is obese. In addition, if the animal is found to have fleas or other external parasites, it will be treated with a long-acting flea/tick treatment at an additional charge ($28). We will gladly prepare a written estimate if you desire. Please ask the doctor or technician. I consent to authorize over the phone any additional services not listed. I understand you will use reasonable precautions to assure the animal's safety while it is in your care, but will not hold you responsible if the animal should injure itself, escape, fail to eat, become ill or expire. I absolve you of all liability arising from the performance of procedures requested herein. I understand this hospital is not staffed continuously during weeknights (approximately 6:00 p.m. - 7:30 a.m.), weekends or holidays, unless necessary due to emergency care. Patients are monitored periodically and exercised routinely as needed throughout this period. I understand payment is due, in full, when the animal(s) is discharged from the hospital.. Payment will be made through a secure link sent to you via text or email. I have read and understand this authorization and consent.

Signature*

Date*