Diagnostic Testing
Diagnostic Testing
General Information
Today’s Date
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Date of Appointment
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Client Name
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Client Name
First Name
First Name
Last Name
Last Name
Phone Number
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Email
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Patient Information & History
Pet’s Name
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Which test is your pet visiting us for?
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ACTH Stimulation testing
Low Dexamethasone Suppression testing
MSU Thyroid Panel
Thyroid Level Recheck (on thyroid medications)
Fructosamine recheck
Glucose curve
Phenobarbital / Zonisamide / Levetiracetam / Seizure medication testing
GI Panel
Itraconazole levels / Histoplasmosis antigen testing
When did your pet last receive their Vetoryl/Trilostane?
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When time your pet last receive their Vetoryl/Trilostane?
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12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
When did your pet last receive their Thyro-tabs or Methimazole?
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When time your pet last receive their Thyro-tabs or Methimazole?
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12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
When did your pet last receive insulin and how many units were administered?
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What brand & form of food are you feeding this pet? (ex: Purina Pro Plan, Hill’s Sensitive Skin & Stomach, etc)
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How much food are you feeding this pet and how often? (ex: 1/2 cup twice daily)
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When did your pet last eat and drink?
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Wen did your pet last urinate and defecate?
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Please give details regarding any the main symptoms/concerns
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Services
What medication(s), monthly preventative(s), or prescription food do you need refilled today?
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Options for prescriptions: refilled the prescription in clinic, authorize prescription via our VetCove online pharmacy, or pick up a paper prescription for third party pharmacies. We do not fax prescriptions or authorize prescriptions over the telephone.
Does this pet need any additional services while with us today?
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Nail trim
Anal gland expression
None
Do you have any specific questions for the veterinarian today?
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Consent to Treatment
Does this pet have a history of requiring injectable sedation due to high fear, anxiety, stress, or aggression?
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Yes
No
*Patient charts will be reviewed by staff upon receipt. If your pet’s chart states injectable sedation is required and “no” is selected, we will have you sign documents at drop off*
Authorization for Injectable Sedation
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Please remember to give pre-visit medications (trazodone, gabapentin, acepromazine) as prescribed the evening before and 2-3 hours prior to your appointment
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Agree
I authorize the following monetary amount for additional services outside of the cost of the annual wellness package
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$400
$500
$600
I understand that NHPC may not contact me regarding the status of my pet prior to 4:00pm, unless there is an emergency.
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Yes
No
Drop-offs are triaged and worked on in between scheduled appointments
Signature
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