"*" indicates required fields Owner's Name* First Last Pet's Name* TODAY’S CONTACT NUMBER(S): (Primary)*Alternate PhonePreferred Pickup Time for Day Patient: Hours : Minutes AM PM AM/PM When the doctor examines your pet, you have a 10-minute window to reach us at this number. The doctor will proceed with the suggested treatment if we cannot reach you. Please leave the best number possible and stand by for our call or text. REASON FOR VISIT TODAY:* Medical Concern Annual/Vaccines Recheck Lab Bloodwork Bath Other If Other* TIME OF LAST MEAL: Hours : Minutes AM PM AM/PM The doctor will examine if you drop off your pet for a routine annual exam or recheck. However, due to scheduled appointments or surgery, the doctor may not be available to speak with you when you pick up your pet. HEALTH UPDATE:Compared to last visit.Appetite* Normal Increased Decreased Attitude* Normal Better Worse Activity* Normal Increased Decreased Water Intake* Normal Increased Decreased Stools* Normal Increased Decreased Urination* Normal Increased Decreased Pain* Normal Increased Decreased Vomiting* Normal Increased Decreased If vomiting has increased, how frequent?* CURRENT MEDICATIONSAre you leaving medications with us today?* Yes No Medication(s) InformationNameDirectionsTime of Last Dose GivenRefill Needed? (Y/N) Add RemoveFINANCIAL RESPONSIBILITY: Payment is Due at Check-Out. Who will be paying the invoice today?NameNumberCall for approval if treatment charges are over:* $250 $500 $750 Other PROBLEMS, QUESTIONS, OR CONCERNS REGARDING YOUR PET: Please be assured that we provide comfortable quarters for all patients. We prefer that you do not leave valuable items at the clinic that could become misplaced or lost in the laundry. We cannot be held responsible if an item goes missing. If you do leave personal items, please add identification. Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.