Sick Pet Form
Sick Pet Form
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
*
Which symptoms have you noticed? (select all that apply)
Vomiting
Diarrhea
Constipation
Lethargy/tiredness
Loss of appetite
Increased appetite
Excessive drinking
Frequent urination
Coughing
Sneezing
Limping
Shaking/trembling
Hiding/behavior changes
Excessive scratching
Hair loss
Skin Irritation
Itching
Foul odor from ears
Please give details regarding the main symptoms/concerns
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What medications, supplements, or treatments does this pet receive?
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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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Have you noticed any NEW lumps or bumps on your pet?
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Yes
No
Where are the new lumps or bumps?
Does this pet go to any of the following? (please select all that apply)
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Boarding
Daycare
Grooming
Pet Stores
None of the above
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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signature
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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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Clear
Submit
If you are human, leave this field blank.
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