Pet's Name Briefly describe the reason for your pet's visit: How long has your pet had this illness or injury? What is your pet's normal habitat? Which of the following describes your pet's water consumption: Which describes your pet's current appetite? Has your pet's appetite changed recently? What is your pet's normal diet (including treats, table food, etc.) and how much does he or she eat? Which best describes your pet's activity level? Has your pet's activity level changed lately? Have you noticed any changes in your pet's behavior lately? If so, please describe below. Has your pet been showing signs of lameness lately? If so, which leg, and for how long? If your pet is lame, which best describes the lameness? Does your pet have difficulty rising? Does your pet exhibit reluctance to jump or run? Does your pet ever vomit? If so, how often? What is usually vomited? If your pet is vomiting, is there any relationship to eating? Does your pet have diarrhea? Is your pet straining to deficate? Approximately how many bowel movements does your pet have each day? Is your pet coughing? Is your pet sneezing? Does your pet have any nasal discharge? Does your pet have any discharge from the eyes? Has your pet been shaking his/her head or scratching at the ears? Is your pet itching excessively? If your pet is scratching, where are the itchiest spots? Please list any "lumps or bumps" that you have noticed on your pet: Have you found any ticks on your pet recently? Have you found any fleas on your pet recently? Is your pet on heartworm preventative? If your pet is on a heartworm preventative, which one do you give and how often is it given? For cat owners only, has your cat ever tested positive for feline leukemia or FIV? Please list any medications that your pet takes, including over-the-counter medications: If it is necessary to send home medication with your pet, which do you prefer (if possible)? Please list a phone number where you can be reached if necessary: How much may we spend on your pet's diagnosis and treatments prior to calling you? At what time do you plan to pick up your pet? Powell Animal Hospital Drop-Off Policy: Please note that we require all pets staying with us for the day to be current on vaccinations and to have had a negative fecal examination within the past 6 months. If your pet is due vaccinations, your pet will be vaccinated before treatments are performed. Additionally, your pet must be free from both external and internal parasites. If treatment for parasites is necessary, this will be performed at your expense. Authorization: By submitting this form, I authorize the doctors at Powell Animal Hospital to perform the diagnostics and treatments that they feel necessary up to the amount I listed above. I understand that if additional services are necessary, I will be contacted by a doctor so that we can discuss these procedures and their cost. If I cannot be reached, I give my permission for the doctors to perform any necessary emergency treatments that may be needed to stabilize a life-threatening condition. I agree to assume all financial responsibility for these treatments in the case of an emergency. I have read the above statement, and I - (required)
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