Patient History Form

ADVERTISEMENT

PATIENT HISTORY FORM
_______________________________________
__________________________________________
Owner’s Name (print please)
Pet’s Name
When was the last time your pet ate? _________________________________________________
Does your pet have any medical conditions such as a hernia, retained baby teeth, or retained testicle? (Circle)
Has your pet had any surgeries, medical conditions, or vaccine reactions?
Yes
No
If yes, please indicate________________________________________________________________
Has your pet had any coughing, sneezing, vomiting, or diarrhea?
Yes
No
If yes, explain______________________________________________________________________
If we find your pet needs a dewormer, may we administer medication to treat it?
Yes
No
If we find your pet needs antibiotics, may we dispense medication?
Yes
No
Yes
No
Would you like pre-surgical blood work for your pet 0-7 years $45 8 plus years $79
If your pet licks or chews, an E-Collar will be necessary. Do you want one today?
Yes
No
Is your pet on any medications or supplements?
Yes
No
If yes, please list name, dose, and time last given________________________________________
Female Dog/Cat Only Questions:
Has she had a litter?
Yes
No
If so when ___________________________________________________________________________
Has she had any abnormal discharge?
Yes
No
Female Dogs Only Questions:
Has she been in heat?
Yes
No
If so, when was her last heat cycle_______________________________________________________
Has she had an abnormal heat cycle?
Yes
No
If so, what signs did she have __________________________________________________________
If so, describe the characteristics ______________________________________________________
ALL DOG Questions:
Is your dog on heartworm prevention?
Yes
No
If yes: What product__________________________ When was it last given __________________
Do you give it monthly?
Yes
No
If no, how many doses have been missed ________________________________
Would you like a heartworm test for your dog for an additional fee of $18.00
Yes
No
Heartworm Testing Waiver (Sign only to decline)
A Heartworm test is recommended on all dogs over 6 months of age prior to elective surgeries. Heartworm disease can
lead to severe complications, and even death, under or after anesthesia/surgery. I understand that the doctors at Spay N
Save Animal Clinic recommend heartworm testing before surgery to rule out heartworm disease, with or without
the use of preventative. I have read and understand the risk involved and choose to decline heartworm testing at this
time. I do hereby release Spay N Save Animal Clinic and its staff from any liability should injury and/or death occur as a
result of heartworms not being detected before surgery.
I, the owner (or authorized agent) decline the pre-surgical heartworm test and fully understand the additional risks
involved if my dog is heartworm positive.
Client signature __________________________________ Date _____________
Doctor’s Initials _________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical

Related Categories

Parent category: Business
Download
Go