Sick Appointment Drop Off | Vida Veterinary Care

Client Name

First

Last

Pet’s Name

Phone number (s) where you can be reached today

*If any of your contact information has changed, please notify us*

To Better Assist Us in Treating Your Pet, Please Answer the Following Questions. Thank You!

Please check any applicable signs you have seen in your pet or list symptoms below. If a box is checked, please also answer the bulleted questions below:

Increased appetite

Yes

Increased urination

Yes

Are we having accidents in the house?

Are we urinating larger amounts, more frequently, or both?

Inflamed/Runny eyes

Yes

Vomiting

Yes

How many times?

Anything in the vomit?

Any chance of foreign material being ingested?

Diarrhea

Yes

How many times?

Is there any blood in the diarrhea?

Decreased appetite

Yes

When was the last time your pet ate?

Sneezing

Yes

Nasal discharge

Yes

Coughing

Yes

Any boarding or grooming lately?

Any interaction with other dogs?

Difficulty breathing

Yes

Seizures

Yes

How many seizures did your pet have and how long did they last?

Any history of seizure like activity?

Did your pet lose control of their bowels during this episode?

Blood in urine

Yes

Straining to defecate

Yes

When was the last time they defecated?

Drinking excessively

Yes

Not drinking/drinking less

Yes

Weight gain

Yes

Weight loss

Yes

Lethargy (low energy)

Yes

Hyperactivity

Yes

Itching

Yes

Where is your pet itchy?

Any history of allergies?

Shaking head

Yes

Inflamed or smelly ears

Yes

Any Other symptoms

Yes

If Yes, Please list other symptoms

Any medical history or chronic conditions? Please list if applicable.

Is your pet current on vaccines?

Yes

When did the symptoms start?

Have you administered any treatments at home?

Please list any medications and supplements your pet is currently taking (including over the counter medications):

Please list your pet’s current diet (brand, amount & frequency)

Has your pet traveled recently? If so, where and for how long?

Is your pet currently on heartworm prevention?

Yes

What type of heartworm preventative is your pet on?

What was the date the last dose of heartworm preventative was given?

Has your pet missed any heartworm preventative doses?

Is your pet on flea/tick preventative?

Yes

What type of flea/tick preventative is your pet on?

What was the date the last dose of flea/tick preventative was given?

Has your pet missed any flea/tick preventative doses?

I authorize Vida Veterinary Care Centennial to defer to doctor’s discretion for services prior to contacting me.

I authorize doctor discretion

Yes

If our efforts to contact you fail, would you like us to proceed with the recommended services and/or treatments?

Yes

Please initial that you have read and understand the above statement(Required)

I authorize Vida Veterinary Care and its agents and representatives to perform diagnostics indicated above, medical treatments, or any other procedures that, at the doctor’s discretion, may be useful to treat my pet. I authorize the use of anesthetics if needed. I have been advised as to the nature of the diagnostics, treatments and risks involved. I acknowledge that results cannot be guaranteed. I am aware all reasonable care will be taken by Vida Veterinary Care for the safe treatment and return of my pet. I release Vida Veterinary Care and its agents and representatives from any and all liability.

Signature of Owner or agent(Required)

Date

Owner or Agent Print Name

I am aware that Vida Veterinary Care is committed to the safe treatment and return of my pet, and that, if necessary, emergency or life-saving measures will be taken even if I cannot be reached.

Please initial that you have read and understand the above statement(Required)

Please elect CPR or DNR status in unlikely case of cardiac or respiratory arrest.

CPR

DNR

I, the undersigned, certify that I am the owner or duly authorized agent for the owner of the Patient, described above and accept full financial responsibility. I authorize the veterinarians, and agents of Vida Veterinary Care to perform the services listed above and understand that support staff will be utilized at the doctor’s discretion. I accept that full payment for services and products is expected at the time my pet is discharged.

Signature of Owner or Agent(Required)

Date

Owner/authorized agent printed name

First

Last

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