Drop-Off ReleaseOwner Name First Last Pet Name First Did your pet eat this morning? Yes NoHas your pet had any reactions to medications? Yes NoIf so, describe;Has your pet had any reactions to vaccines? Yes NoIf so, when and what vaccine?Has your pet had any reactions to anesthesia? Yes NoIf so, when?Is your pet currently on any medications? Yes NoPlease list;What is your pet here for today? (Check all that apply) Vaccines Grooming/Bath Ill/Sick OtherExplain:History: Is your pet showing any of the following symptoms? (Check all that apply) Lethargy Poor Appetite Seizures Coughing Sneezing Scratching Increased thirst Scooting rear end Weight loss Weight gainVomiting? YesHow long has your pet been vomiting?When does the pet usually vomit? (Morning, Night, Random, etc.)How many episodes of vomiting have been observed per day?What does the vomitus consist of? (list all that apply: Food, Bile, Water, Hair, Plastic, Other)Does your pet have a history of chewing on toys, rocks, rawhides, etc?Diarrhea? YesHow long has your pet had diarrhea?How often has the diarrhea occurred?Does the diarrhea contain blood or mucus?Has your pet had any new foods, treats, or human food recently?Urinating issues? YesMore or less frequently than usual?Does your pet strain to urinate?Have you observed blood in the urine?Limping? YesHow long has your pet been limping?Which limb is affected?Is there any history of trauma?Unusual lumps or bumps? YesDescribe the location and see the lump form;How long have the growths been present?May we perform bloodwork on your pet if the Dr. deems it necessary? Yes NoMay we perform X-rays on your pet if the Dr. deems it necessary? Yes NoMay we sedate/anesthetize your pet if the Dr. deems it necessary? Yes NoSignatureDate MM slash DD slash YYYY PhoneCAPTCHAΔ
