Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Reason for today's visit: (please select all that apply) *

Wellness exam / vaccines
Illness
Injury

Please explain illness: *

Please explain injury: *

What would you like doctor to know about your pet's health? *

What would you like doctor to know about your pet's illness? How long have they been dealing with the illness? *

What would you like doctor to know about your pet's injury? When did injury occur? *

Pet's Name *

How is your pet's appetite? *

Normal
Increased
Decreased

What type of food do you feed? *

When was the pet's last meal? *

How is your pet's water consumption? *

Normal
Increased
Decreased

Has your pet been vomiting? *

No
Yes

Please explain.

How is your pet's stool? *

Normal
Abnormal

Please explain.

How is your pet's urination? *

Has your pet shown any sign of:

Please explain your pet's bad breath. *

Please explain your pet's behavior changes. *

Please explain your pet's breathing problems. *

Please explain your pet's coughing issues. *

Please explain your pet's depression. *

Please explain your pet's difficulty moving. *

Please explain your pet's excessive sleeping. *

Please explain your pet's bleeding gums. *

Please explain your pet's limping. *

Please explain your pet's loss of balance. *

Please explain your pet's restlessness. *

Please explain your pet's scooting. *

Please explain your pet's scratching and chewing. *

Please explain your pet's head shaking. *

Please explain your pet's skin masses and lesions. *

Please explain your pet's sneezing. *

Please explain your pet's weight change. *

If Other, please explain *

Is your pet on heartworm prevention? *

Yes
No

Flea prevention? *

Yes
No

Current on vaccinations? *

Yes
No

Is your pet on any medications? *

Yes
No

If yes, what medications and when were they last given?

Is there anything else needed while pet is here (check all that apply)? *

Please specify other service *

(Feline Only) Does your pet go outside?

Yes
No

I understand if my pet is found to have fleas, he/she will be treated at my expense. *

I have read and understand.

Do we have your permission to sedate/anesthetize your pet if necessary in order to perform an exam, diagnostic test, or agreed upon surgical procedure? *

Yes
No

I understand that there may be restrictions to my pet’s activity and agree to follow the recommended post-operative instructions after this procedure. *

I have read and understand

I understand that CVC recommends current blood work (4 weeks or less) for any procedure requiring anesthesia regardless of age. *

I have read and understand

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. *

I have read and understand

The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

Signature *

Clear Signature

Today's Date *

Drop-off Sick Form

Drop-off Sick Form

Ready for a visit?

Questions?

Location

Contact Information

Hours