Pet Evaluation and Treatment Consent Form

Pet Information

• Animal's Name
• Owner's Name*

  Please enter your name.
Please answer all questions and elaborate on any abnormal symptoms or behavior in the area provided.
• Reason For Visit*

  Please enter a message.
• When did you first notice changes?*

  Please enter a message.

• Appetite*

  • Decreased
  • Normal
  • Increased

  Please make a selection.

• Water Intake*

  • Decreased
  • Normal
  • Increased

  Please make a selection.

• Urination*

  • Less Frequently
  • Normal
  • More Frequently

  Please make a selection.
• Diarrhea* Yes No

  Please make a selection.
• Vomiting* Yes No

  Please make a selection.
• Frequency of Diarrhea?
• If Vomiting, How Often?
• Consistency of Diarrhea?
• Material Vomited?
• Coughing/Sneezing/ Respiratory Problems?* Yes No

  Please make a selection.
• Walking Normally?* Yes No

  Please make a selection.
• If yes to respiratory problems, please explain:
• Frequency of Respiratory Issues?
• If no to walking normally, please explain:

• Activity Level*

  • Depressed
  • Normal
  • Above Average

  Please make a selection.

• Skin/Coat (check all that apply)*

  • Dry
  • Normal
  • Oily
  • Itchy
  • Inflamed/Red
• Does your pet have any major medical problems?* Yes No

  Please make a selection.
• Is your pet on any medications?* Yes No

  Please make a selection.
• If yes to medical problems, please list:
• If yes to medications, please list:
• Any other changes in overall health?
• When did your pet last eat and drink?*

  Please enter last time your pet drank

• Please initial one:

  • Perform exam only until I am contacted.
  • Treat and perform diagnostics as needed.
  • Treat and perform diagnostics as needed up to the authorized amount set below.
• Set amount you are authorizing to spend on treatment and diagnostics:

I understand that diagnostics and treatment may be delayed if I cannot be contacted by phone

• Signature*

  Please enter your name.
• Primary Contact Number*

  Please enter your phone number.

  This isn't a valid phone number.
• Today's Date*

• Best time to reach you:

  • I agree that that this document may be electronically signed, and that any electronic signature appearing on this document is the same as handwritten signature for the purpose of validity, enforceability, and admissibility.*

  Please make agree to terms