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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