0557 - Southwest Veterinary Hospital

Name*

First NameLast Name

Email*

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Phone Number*

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Pet's Name*

Please enter your pet's name.

Has your pet been exposed to a person with suspected or confirmed COVID-19?*

YesNo

(Please inform us so that we have the information we need to safely treat and diagnose your pet.)

Briefly, what is your concern about your pet?*

Please describe the reason for your pet's visit.

How long has this problem/issue been going on?*

Please describe the length of time that this problem or issue has been occurring.

Has your pet been treated with anything at home?*

Please describe any treatments that you have given your pet at home.

Any changes in the urine?*

YesNo

Describe changes in the urine:

Please describe changes in your pet's urine

Any changes in the stool?*

YesNo

Describe changes in the stool:

Please describe any changes in your pet's stool.

Is your pet eating and drinking normally?*

YesNo

Describe changes in eating habits:

Please describe any changes in your pet's eating habits.

Any coughing or sneezing?*

YesNo

How long has the coughing and sneezing been happening?

Please describe how long your pet has been coughing or sneezing.

What flea prevention and heartworm prevention are you currently using? When was it last given?*

Please enter the name of your flea/heartworm prevention and the date it was last given.

Does your pet board or get groomed?*

YesNo

Did your pet eat today, and if so, when?*

Please enter what your pet ate today and when.

What are you currently feeding your pet?*

Please describe what you are currently feeding your pet.

Other pets in the household:

Describe all other pets in your household.

Is it okay for the doctor to run appropriate diagnostics today, like bloodwork and urinalysis?*

YesNo

Did your pet receive any medications this morning?*

YesNo

Do you need any medication refills?*

YesNo

Please list all medications you are giving your pet:

Please enter all medications that you are giving your pet.

Anything else we should know:

Please describe anything else that we should know,

If necessary for examination, do we have permission to sedate or anesthetize your pet?*

YesNo

To effectively diagnose and treat many problems x-rays, blood tests and other procedures may need to be done. We will notify you before undertaking these tasks as to their need and cost. In the event of a life-threatening condition we will make every attempt to stabilize your pet and notify you as to the extent of the problem as soon as possible.

I HEREBY AUTHORIZE STIERN / SOUTHWEST VETERINARY HOSPITAL TO GIVE STANDARD AND ACCEPTED TREATMENT NECESSARY FOR THE WELL BEING OF MY PET, AND AGREE TO BE RESPONSIBLE FOR ANY AND ALL COSTS INCURRED IN CONNECTION WITH TREATMENT. I UNDERSTAND ONLY MINIMUM DIAGNOSTICS AND/OR TREATMENT WILL BE ADMINISTERED TO MY PET UNTIL WHICH TIME THAT I CAN BE CONTACTED FOR AUTHORIZATION.

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Date*

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Owner Information

Pet Information

Agreement