Where Cats Rule - Hartland Cat Hospital
[pic]Where Cats Rule!!!
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Examinations and Drop-Off
Cats Name ________________________ Cats Age__________ Owner _____________________
Phone ________________________________________
Reason for Exam ___________________________________________________________
Is your pet up to date on vaccines? Yes / No
If yes, when and where were vaccines given? ___________________________________________
Duration of Symptoms (if applicable)_________________________________________________
Is patient on flea or heartworm prevention?___________ If so, what kind?____________________
Any known allergies?_______________ FIV/FeLV Tested?_______ Date______ Results_______
Is your pet currently micro-chipped? Yes / No
Is it easier to give Pills? ________ Liquid? ________
Brand of Food _____________________ Type: Dry Can Dry/Can
Is your pet currently on any medications?______ If so, please fill out back side of form.
Please Select Appropriate Choice:
Housing: (INDOOR) (OUTDOOR) (BOTH)
How many pets in household?__________
Appetite: (NORMAL) (DECREASED) (INCREASED) (NOT EATING) How long? ___________
H2O intake: (NORMAL) (DECREASED) (INCREASED) (NOT DRINKING) How long? ______
Vomits: (NEVER) (OCCASIONALLY) (FREQUENTLY) How often and what? ______________
BM: (NORMAL) (STRAINS) (PAINFUL) (HARD/DRY) (BLOODY) (DIARRHEA) how often?
_______________________________________________________________________________
Urinary: (NORMAL) (STRAINS) (PAINFUL) (BLOOD) (OUTSIDE LITTER BOX)
Activity Level:
(NORMAL) (VERY ACTIVE) (LETHARGIC) (MORE ACTIVE) (LESS ACTIVE)
Respiratory: (NORMAL) (SNEEZING) (COUGHING) (DISCHARGE) what color?____________
Parasite Control: All patients will be inspected for fleas at the time of admission. If fleas are present, a Capstar tablet will be given at the expense of the owner.
I give Authorization for the Following:
Exam ____ Blood Work ___ X-ray ___ Sedation ____ Medication ____ UA ____ Vaccines _____
Please ask for prices if needed.
I hereby authorize the veterinarian to examine, prescribe for and treat the above pet. I assume responsibility for charges incurred in the care of this animal. I understand that theses charges are due at the time services are rendered.
Signature ________________________________________ Date __________________________
Would you like to be called prior to extensive diagnostics not checked above? ________________
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Veterinary Tech:
Temp_____ Weight_____ Gained______ Lost_____
Patient Behavior: BAR______ QAR_______ Lethargic______ Disoriented______
Date of Last BW: _____________________________
Results: _____________________________________
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