"*" indicates required fields Pet's Name*Pet’s species* Cat Dog Exotic Pet Gender* Male Male Neutered Female Female Spayed Age*Diet and Treats*Does your pet ever go outside?* Yes No Heartworm Prevention and last dose*Flea/tick prevention and last dose*Current Medications, Vitamins or Supplements: Please include dosage, frequency of administration, last dose. Please include any human medication or supplements you may have given at home.*Primary Concerns Today (Please check the boxes that apply): General Skin Ears Eyes Respiratory Urinary Gastrointestinal Musculoskeletal Nervous System Primary Concern Today/When did it start/Getting better, same or worse:*Previous/Current Medical Conditions (i.e. kidney disease, diabetes, hypothyroid…etc):*General* Lethargy Weight loss Weight Gain Increased Appetite Decreased appetite Other Other*Skin* Fleas or ticks Itching/scratching Scabs Bleeding Check lump/mass I approve a skin infection or lump cytology to be started once my pet is admitted to check for infection or to check to see if a lump is a tumor Please call prior to any diagnostics Other Other*Where on pet:*Ears* Shaking head Itching /scratching Scabs Bleeding/Disharge Redness Swelling Other I approve an ear cytology to be started once my pet is admitted Please call prior to any diagnostics Other*Eyes* Red Swollen Discharge Crusting Bleeding Squinting Other I approve an eye stain to be done once my pet is admitted to check for ulcers on the cornea Please call prior to any diagnostics Other*Respiratory* Fainting Purple or blue gums/tongue Labored breathing Wheezing Coughing Sneezing Discharge from nose Other I approve chest x-rays to be started once my pet is admitted Please call prior to any diagnostics Other*Urinary* Blood in urine Straining to urinate Peeing more frequently Drinking more frequently Accidents in house Other I approve a urinalysis to be started once my pet is admitted Please call prior to any diagnostics Other*Gastrointestinal* Vomiting Diarrhea Blood in vomit or diarrhea Mucus in vomit or diarrhea Worms in vomit or diarrhea Bloated abdomen History of eating trash or toys Non-productive retching Other Other*Musculoskeletal* Limping Difficulty going upstairs/onto furniture I approve x-rays to be started once my pet is admitted Please call prior to any diagnostics Limping area* LEFT FRONT RIGHT FRONT RIGHT HIND LEFT HIND Duration*Select one:* After exercise After Resting What caused limping?*Nervous System* Seizures Head tilt Circling Duration*Frequency*Date/time of last seizure and length:*Direction* Left Right Direction* Left Right Can we start on diagnostics prior to calling you if needed* Yes No Sedation may be needed to perform diagnostics on your pet, especially for things like x-rays.* The doctor has my permission to sedate my pet if needed Please call prior to sedation if warranted Best Contact Number for Diagnostics/Treatment/Results:*Best Contact Number for Pick-up* Same as above Other Other phone:*Exotic Pet SectionPlease provide the following information:Enclosure setup:*Lighting* UVB BULB HEAT LAMP NIGHT BULB DAY BULB NONE Other Other*Heating* HEAT PAD HEAT LAMP HEAT ROCK DAY BULB Other Other*Humidity Levels:*Temperature Range:*Water type (bottle/bowl) and availability:*Last shed, if applicable:Was it normal? Yes No CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
