Drop Off Form for Pet Health Physical Exam, Rechecks, Dogs, Cats, Baths, Grooming : American Animal Care Center Fremont, Ca Veterinarian, Pet

American Animal Care Center Drop Off Form
Last Name: ___________________________________
Date: _________________ ID: _____________________

Yes

Please help us help your pet by providing us with as much detailed information as possible

Do you have pet health insurance?

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Have you seen your pet passing worms?

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Has your pet had any illness in the last year?

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Has your pet had any surgery in the past year?

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Has your pet ever had a seizure?

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Does your pet get table scraps?

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Did your pet eat in the last 4 hours?

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Does your pet ever strain to urinate?

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Has there been any recent vomiting?

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Has your pet been coughing?

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Has your pet been sneezing?

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Has your pet been gagging?

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Any listlessness?

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Any weakness?

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Any lameness? Circle leg: LF LR RF RR

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Shaking of the head?

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Scratching? Where?

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Significant hair loss?

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Scooting?

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Lumps or bumps?

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Bad breath?

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Unusual discharge?

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Diarrhea?

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Constipation?

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Stiffness?

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Behavior changes?

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We will call you with an update and let you know when your pet is ready to go.
Phone Number: _____________________________

	Normal?	Increased?	Decreased?
Drinking?	[ ]	[ ]	[ ]
Appetite?	[ ]	[ ]	[ ]
Urination?	[ ]	[ ]	[ ]
Defecation?	[ ]	[ ]	[ ]
Weight?	[ ]	[ ]	[ ]

Pet Name: _____________________________________

Reason For Visit Today
__________________________________
__________________________________
__________________________________
_______________________________

Has your pet been examined elsewhere for the same condition?
Yes No

If yes, where?
__________________________________
__________________________________
___________________________

What medication is your pet now taking?
__________________________________
__________________________________
___________________________

Is your pet allergic to any food or medication?
Yes No
If yes, please describe
__________________________________
__________________________________
___________________________

Costs
[ ] Please call me with an estimate before you do anything.

[   ] I authorize treatment up to (check one)
       [   ] $100
       [   ] $200
       [   ] $300
       [   ] $400

Notes to Doctor & Staff

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