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*Email* 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 ComplaintPlease 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 other symptoms (please explain)Please describe in further detail the symptoms above, including location, if appropriateHow 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 explainIs your pet on any medications? Please list and note time givenAre there any other services that you would like to be performed (e.g. vaccines, heartworm test, prescription refill, etc.)?Treatment / Testing Consent (choose one) 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. If your pet requires general anesthesia, we will give you an appropriate estimate and surgery release form prior to leaving your pet with us. You will be asked to sign a printout of this form when you bring your pet in.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
