We ask that you either fill out the Recheck Form below and send it to us electronically (submit) or download it below and complete the form and email it to us at info@thesamsclinic.com for your pet’s appointment.

Please fill out the forms prior to the appointment.

Soft Tissue Patient History Form

IF YOUR PET IS EXPERIENCING ANY vomiting/diarrhea/coughing/sneezing PRIOR TO THE APPOINTMENT PLEASE CALL IMMEDIATLY AS WE MAY HAVE TO RESCHEDULE THE APPOINTMENT

Date *

YYYY

Name *

Client first and last name

First Name

Last Name

Pet's Name *

First Name

Last Name

Phone *

Best contact number for today's visit

(###)

###

####

Did your primary veterinarian refer you? *

Who may we thank for this referral? *

Has your pet had any X-rays or treatments at another hospital? (WE KINDLY ASK YOU TO CONTACT EACH LOCATION TO REQUEST X-RAYS AND RECORDS TO BE FORWARDED TO info@thesamsclinic.com PRIOR TO YOUR APPOINTMENT) *

If yes, please provide hospital location(s) and date(s) imaging was performed

Text

Has your pet had any blood work performed? *

If yes, please provide hospital location(s) and date(s) diagnostics were performed

Text

What is the presenting complaint/issue that you would like addressed today? *

What treatments has your pet had to address the current issue? *

Does your pet have any new or pre-existing medical issues? (If yes, please explain) *

*Note: If your pet has been recently diagnosed with an infectious disease we will ask for proof of negative lab results or clearance from your primary vet before we can see your pet.

If yes to the above question, are those medical issues currently being treated? *

(Write N/A if does not apply)

Has your pet improved with treatment? *

If this issue is a mass, has the mass grown or changed in size, shape or appearance? *

If this is a mass, has the mass been biopsied or aspirated? *

(If yes, when and where were the diagnostics performed?)

Has your pet ever had any diagnostics performed such as CT scan, MRI or an ultrasound? *

If yes, when and where were the diagnostics performed?

Has your pet had any previous surgeries? *

What are your goals for today's appointment? *

Has your pet been on ANY of the following anti-inflammatory medications? *

Metcam/Meloxicam/Meloxidyl

Rovera/Rimadyl/Carprofen

Galliprant

Previcox

Other NSAID

NONE

If Yes to the above question, please answer the following: *

Write N/A if does not apply 1. What is the dose in milligrams (mg)? 2. What is the frequency? 3. Duration of treatment (how long was the treatment prescribed)? 4. When was the last dose administered?

Has your pet been on ANY of the following corticosteroids? *

Prednisone

Prednisolone

Cortisone

Temaril-P

None

If yes, to the above question, please answer the following: *

Type N/A if does not apply 1. What is the dose in milligrams (mg)? 2. What is the frequency? 3. Duration of treatment (how long was the treatment prescribed)? 4. When was the last dose administered?

Please list all other medications/supplements/injections your pet has had within the last 30 days: *

Has your pet had any vomiting, diarrhea, coughing or sneezing in the last 30 days? *

If Yes, please provide details:

Does your pet have any known allergies or sensitivities to foods or medications? *

If Yes, please provide details:

Does your pet have any known allergies or sensitivities to sedation or anesthetic drugs? *