Name *
Email *
Phone *
Visit Details
Reason for today’s visit: (please select all that apply) *Wellness exam / vaccines Illness Injury
Pet’s Name *
Health Status
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
How is your pet’s stool? *Normal Abnormal
How is your pet’s urination? *Normal Increased Decreased Painful Straining
Has your pet shown any sign of: (Check all that apply)Bad breath Behavior changes Breathing problems Coughing Depression Difficulty with rising, sitting, jumping, or stairs Excessive sleeping Gums bleeding Limping Loss of balance Restlessness Scooting Scratching / chewing Shaking head Skin masses/lesions Sneezing Weight changes Other
Prevention & History
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
Additional Services
Is there anything else needed while pet is here (check all that apply)? *Nail Trim Heartworm test FeLV/FIV testing Check ears Clean ears Express anal glands Fecal testing Update vaccines if possible (Dr. Discretion) Microchip Blood work Refill of preventions Other
(Feline Only) Does your pet go outside?Yes No
Any other notes to the team about your pet’s appointment:
Authorization & Agreements
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
Today’s Date *
