Owner:                                        Pet:                                                 Neutered: Yes/No

Has your address or phone # changed since your initial visit?

If so please list new information:
Street:                                       City:                       Zip:                           Phone:
 
Are all your pet's vaccines up to date?
 
What is your main reason for this visit?:
 
 
List any other lesser concerns you would like us to take care of.
 
 
If your pet is ill please circle the number next to the symptoms or changes you
have observed:

 1 Appetite       2 Activity      3 Behavior     4 Thirst      5 Stool
 6 Urine          7 Weight        8 Diarrhea     9 Vomiting   10 Retching
11 Wheezing      12 Coughing     13 Gagging     14 Sneezing   15 Limping
16 Seizures      17 Trembling    18 Twitching   19 Tearing    20 Scooting
21 Scratching    22 Chewing      23 Shedding    24 Straining  25 Swelling
26 Lumps         27 Scabs        28 Sores       29 Cuts       30 Bleeding
31 Pain          32 Odor         33 Growths     34 Discharge  35 Eyes
36 Ears          37 Nose         38 Skin        39 Gait       40 Swallow
41 Breathing     42 Whimpering   43 Fever       44 Frightened
 
List any other symptoms you have noticed that were not included in the above
list.  If you would like to further explain any above circled symptoms please
use this space
 
 
 
List just the numbers of the above circled symptoms in the order that you first
noticed them.
 
List just the number of the above circled symptoms and next to each number write
the number of days each has been present.
 
Where appropriate list just the number of the above circled symptoms and next to
each write the number of times a day that symptom occurs
 
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   I may be reached at the following number:
   The best time to reach me at this number is between the hours of:
   I will be hard to contact so I will call at:
   I must pick up my pet no later than:
 
IF YOU ARE DROPPING YOUR PET OFF PLEASE UNDERSTAND THAT IT IS VERY IMPORTANT THAT WE BE ABLE TO CONTACT YOU FOR FURTHER INFORMATION.  IT IS ALSO IMPORTANT THAT WE BE ABLE TO CONTACT YOU INORDER TO GET YOUR PERMISSION TO PROCEED WITH VARIOUS DIAGNOSTIC WORK OR TREATMENT WHICH WE DID NOT GET YOUR OK FOR ON THE ESTIMATE SHEET. 

WE WILL PERFORM ONLY THE WORK THAT WE HAVE RECEIVED YOUR OK ON.  IF YOU WILL BE HARD TO REACH IT IS VERY IMPORTANT THAT YOU STAY IN CLOSE CONTACT SO THAT WE CAN GET YOUR PERMISSION FOR FURTHER WORK WHICH MAY BE NEEDED.    

List the number of the symptoms which have gotten progressively worse.
 
List the number of the symptoms which have gotten progressively better.
 
List the number of the symptoms which have completely disappeared.