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?

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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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