Name
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First and Last name
First Name
Last Name
Pet's Name:
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What are your goals for today's appointment?
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The best contact number today for this appointment?
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(###)
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Who may we thank for the referral (clinic name or doctor)
Pet Insurance provider and policy number if applicable:
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Please provide hospital names and locations for any medical records and diagnostics performed:
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Has your pet had blood/lab work performed in the last month?
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Has your pet been showing signs of lameness/discomfort? If so, which limb?
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Is the lameness/discomfort worse when getting up from a lying position?
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Is lameness worse during or after exercise?
What is your pet's current level of activity/exercise?
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If yes to the above question, what is the name of the medication and how long have they been/were taking it? When was the last dose?
Please list all other medications/supplements/injections your pet has received in the last 30 days:
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Has your pet improved with any form of treatment?
If yes to the above question, are those medical issues/conditions currently being treated?
Has your pet had any vomiting, diarrhea, coughing, or sneezing in the past 30 days?
Does your pet have any known allergies or sensitivities to food, medication, or environment?
Has your pet ever had an allergic reaction to sedation type drugs and anesthetic drugs during/after a procedure?
Please list any conditions that your pet has been diagnosed with that fall under and of the following categories:
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Please describe below
If checked any conditions, please explain:
Has your pet ever shown behavior such as blanket chewing, cage biting, or jumping?
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The doctors and technicians may need to administer a sedative, take X-rays, and perform blood work to diagnose your pet’s ailment. Do you consent to these procedures?
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Have you had a fever or any symptoms of illness in the last 14 days? Have you been exposed to anyone testing positive for Covid-19 in the last 14 days?:
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Signature :
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