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Westridge Pet Hospital & Wellness Center Drop Off Examination Request
 
 
To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.
   
Your Name
Phone
E-mail
The information requested will tell us the issues you would like to have addressed. It is important for you to be as specific as possible. If we need additional information, we will call you at the number you provide.
Thank you.
Pet Name
Presenting Complaint
Please check all symptoms
that apply to your pet
Vomiting
Diarrhea
Constipation
Decreased appetite
Decreased energy
Weight loss
Weight gain
Straining to urinate
Increased urination
Decreased urination
Coughing
Panting
Difficulty breathing
Seizures
Scooting
Scratching
Limping
Hair loss
Pain
Growths
Please describe in further detail the symptoms above, including location, if appropriate
How long has your pet had these symptoms?
Has your pet been treated for the same condition in the past?
Can you associate this issue with a particular incident (e.g. injury, diet change, ingestion of foreign substance/toxin, etc.)? Please explain
Is your pet on any medications? Please list and note time given
Are there any other services that you would like to be performed (e.g. vaccines, heartworm test, prescription refill, etc.)?
Treatment / Testing Consent (choose one)
If your pet requires general anesthesia, we will give you an appropriate estimate and surgery release form prior to leaving your pet with us.
After examination by the attending doctor, please proceed with tests and/or treatment up to $175 in cost.    
I would prefer a phone call prior to any additional tests/procedures.
Disclaimer (read-only)  
You will be asked to sign a printout of this form when you bring your pet in.
 
When you are finished, click submit to send the form information
 
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