"*" indicates required fields Thank you for entrusting your pet’s care to us today. The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We ask that you provide this information 24 hours in advance. Due to the volume of patients seen per day, patients may not be able to be seen right away. If your pet is in critical condition, we ask that you please contact your nearest veterinary emergency clinic immediately. Owner Name* First Last Phone*Email* Pet's Name* Species Dog / Canine Cat / Feline Late arrivals* I have read and understand If you know that you are going to be late, please contact us to see if we are able to keep your appointment. If you are more than 15 minutes late and you do not contact us, your appointment will be automatically cancelled. Checking In* I have read and understand I understand that I will be speaking with a nurse prior to leaving my pet at Memorial Veterinary Clinic, that can take up to ten minutes. I understand that there is a scheduled drop off and pick up time. Who should we contact to make medical decisions today? (only one person will be contacted)* Owner (Named Above) Someone Else (Named Below) Name Does your pet need vaccinations? Yes No Unsure, would like to discuss recommendations with the veterinarian. Dog vaccines DHPP 1YR DHPP 3 YR Leptospirosis Rabies 1YR Rabies 3 YR Lyme Bordetella Canine Influenza (Bivalent) Rattlesnake Unsure, would like to discuss recommendations with veterinarian Feline Vaccines FVRCP/Distemper 1YR FVRCP/Distemper 3 YR Rabies 1YR Rabies 3 YR Feline Leukemia (FeLV) Rattlesnake Unsure, would like to discuss recommendations with veterinarian Have you noticed any issues/problems with your pet? Are there any concerns for the following:(check all that apply) Increase in appetite Decrease in appetite Increase in drinking Decrease in drinking Weight Loss Weight Gain Itching/Scratching Shaking Head Bad Breath Vomiting Diarrhea Urination Issues Excessive Sleeping Scooting Skin Masses (explain below) Car Sickness Behavioral Concern Other (explain below) Difficulty Rising (ex. Getting into/out of the car or onto furniture.Difficulty jumping onto window sills, cat trees, etc) If Increase in appetite, please explain*If Decrease in appetite, please explain*If Increase in drinking, please explain*If Decrease in drinking, please explain*If Weight Loss, please explain*If Weight Gain, please explain*If Itching/Scratching, please explain*If Shaking Head, please explain*If Bad Breath, please explain*If Vomiting, please explain*If Diarrhea, please explain*If Urination Issues, please explain*If Excessive Sleeping, please explain*If Scooting, please explain*If Car Sickness, please explain*If Behavioral Concern, please explain*If Other, please explain*If Difficulty Rising, please explain*For Skin Masses* Drop files here or Select files Max. file size: 512 MB. Please upload the image of skin massesFor skin masses, please describe where they are located pertaining to the dog's left or right side:*If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? Yes No If yes, please explain the adverse reaction to any medications, vaccination, or other procedure*Has your pet any surgical procedures in the past? Yes No Surgical Procedures What brand and type of food do you feed your pet? Do you have insurance for your pet?* Yes No Do you give your pet heartworm or flea/tick preventative?* Yes No If so, which ones? Do you wish to take home flea/tick/heartworm prevention today?* Yes No Unsure, speak with a veterinarian about recommendations for my pet Have you seen any fleas or ticks on your pet?* Yes No Do you have other pets?* Yes No Does your pet come into contact with other dogs? None Boarding Grooming Dog Parks Other Please check all that apply Is your pet on any over the counter or prescription medications?* Yes No List current medicationWas your pet last seen by a veterinarian at Memorial Veterinary Clinic?* Yes No Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations. I understand that financial responsibilities for services are rendered at the time of discharge.* I have read and understand I give Memorial Veterinary Clinic authorization to treat as discussed above.* I have read and understand Social Media/Photo Permission: Do we have your permission to post photos of your pet online?* Yes No Day Admission: Once your pet has been examined by a veterinarian, we will contact you to discuss the next step in your pet's treatment plan. Please be advised that our team is working hard to treat multiple patients per day. We strongly recommend that the designated contact be available by phone throughout the day, as Day Admissions are based on a triage system. In the event that we cannot reach you after your admission and your pet has been examined by a veterinarian.How would you prefer us to proceed?* In the event that I miss the veterinarians call, I prefer to be contacted prior to any additional services being performed beyond an examination and halt treatment. I understand that the veterinarian will wait up to 30 minutes to hear back from me. I understand that by not contacting the veterinarian within the allotted time frame, my pet may be subjected to a delay in treatment. In the event that I miss the veterinarian's call, I authorize the veterinarian to perform ALL diagnostics and treatments that are recommended. In the event that I miss the veterinarians call, I only authorize diagnostics and treatments up to a specific dollar amount. In the event that I miss the veterinarians call, I only authorize diagnostics and treatments up to a specific dollar amount. $250 $500 $750 Other I understand that I am still expected to return the veterinarians call, to discuss the recommended treatment plan. Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
