Name



*DO NOT WRITE IN THIS BOX- OFFICE USE ONLY* Location_______________Date______

|GH |repro |parasites |weight |Pregnancy SEX |

|temp |

|Rabies FVRCP FeLV FIV DHLPP K.C. HWT __ Leuk T___ |

|Medications Given: Exam Findings : Surgery__________ Spay Neuter |

Owner Information: How did you hear about us?

|Last name |First name |Phone |2nd phone |

|Address |Apt |City |State |zip |

Pet’s Information: [_]Cat [_]Dog [_]Other

|Name |Breed | M F |Description |AGE |

| | |sex |(colors-markings) | |

|How long have you had this pet? |Last time pet had- Food Water |

|How did you acquire this pet? |Is pet on Heartworm prevention? |

|Has this pet ever been to a Veterinarian? |Ever tested for Heartworms? YES NO |

|Past injuries/surgeries/treatments? |Other tests: |

You may write on the back if needed

|Any health problems ? |

|Any changes in - appetite drinking activity * Has pet - sneezed coughed vomited diarrhea |

|Where does pet live ? outdoor- indoor- both * Allergies- |

|Has pet ever had a seizer? Y N if yes when was last the last one? |

|Has pet ever had a litter? Yes No If yes, how long ago Any deaths, stillborns? |

|Current Vaccines- |

|Current Medications- |

|Reactions to vaccines, medications- |

What is your pet having done today (check boxes ) We strongly recommend Antibiotics for all surgeries

|[ [_] Cat Spay (female) $60 |[ [_] Ear cleaning $5 |[ [_] Rabies (Without Surgery) $15 |

|[_] Cat Neuter (male) $40 |[_] Ear mite treatment $5 |[_] Cat FeLV/FIV Test $25 |

|[_] Dog Neuter 2-40lbs $60 |[_] Tape worm- Cat $10 |[_] Cat Leukemia Vaccine $15 |

|[_] Dog Neuter 41lbs + |[_] Tape Worm- Dog |[_] Cat Distemper aka FRCP $10 |

|[_] Dog Spay |[_] Deworm Strongid |[_] Dog Kennel Cough $10 |

|[_] Pain Meds $10 |[_]Flea Treatment – Cat $10 |[_] Dog DHP Vaccine $10 |

|[_] FREE Rabies With Surgery |[_] Antibiotics (for home) $10 |[_] Heartworm Test $10 |

|[_] Cat Works Male $95 |[_] |[_] Heartworm Prevention |

|[_] Cat Works Female $115 |[_] |[_] Exam – (no Surgery) $10 |

|[_] |[_] |[_] Rx - 1800petmeds (1 year) $10 |

* Pregnancy CAT $10-$25 Dog $10-$40 *Obese $5-$30 *Cryptorchid $10-$100 *Lactating $5-$35

*Animals not picked up at time specified will need to be picked up in Douglasville after extra fees. After 48 hours the nimal will be turned into a local animal shelter.

*By signing below you agree to the procedures you checked above & refuse the ones you did not check

*By signing below you state that you are the owner or agent of this animal and have the authority to consent for anesthetic and surgical procedures.

*By signing below you understand the risks associated with surgery on heartworm positive dogs & Leukemia positive cats. If not checked above and paid for- you are refusing a recommended procedure.

I understand that risk and potential complications, including death, exist with anesthesia and surgery. I accept the stipulation that the veterinarians and staff will not be held liable or responsible for any complications that may occur. I agree to pay any extra charges at time of pick up

Sign _______________________ Date ___________ Paid ______ Owe ________

Cash Only - You will receive paperwork at time of pick up, Put it in a safe place

Duplicates of lost paper work require a written request.

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