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Home
Updates Regarding COVID-19
Our Services
>
Internal Medicine
Dental Care
Diagnostic Medicine
Wellness Exams
Surgery
Grooming, Boarding & Day Care
Hospice & Euthanasia
Pharmacy & Pet Supplies
Office Visits
>
Wellness
>
Pet Care Plan
Flea, Tick & Heartworm
Behavioral Medicine
Exams
Vaccinations
House Calls
Emergency Care
Microchipping
Covid 19 - Pandemic
Our Staff
Doctors
Client Center
ONLINE STORE
Client Forms
>
Anesthetic Release Form
Boarding Release Form
Consent For Treatment
Drop Off Form
Euthanasia Consent Form
New Client Form
Helpful Pet Links
Petly
Downloads
Client Reviews
Contact
Medical Drop-Off Form
*
Indicates required field
Name
*
First
Last
Pet's Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Pet's age
*
Gender
*
Intact Male
Intact Female
Neutered Male
Spayed Female
Breed
*
Color of Coat
*
Phone Number
*
Email
*
What concerns are you coming in for?
*
How long ago did this problem start?
*
Since the problem started have things gotten better, worse, or stayed the same?
*
Has a similar problem happened in the past?
*
Yes
No
Do the doctors have permission to preform diagnostic tests?
*
Yes
No
I want a call before any tests
Is your pet on any medications (prescription or over-the-counter)?
*
Yes
No
Has your pet been recently vaccinated anywhere else?
*
Yes
No
If yes: List name, strength and dosage of medication.
*
List any travel history
*
What brand of food do you feed?
*
How much and how often do you feed? Please include treats
*
Is there any other pertinent medical history we should know about?
*
Please check all that apply
How is you pet's appetite?
*
Normal
Increased
Decreased
None
How is your pet's eyes?
*
Normal
Red
Swollen
Watery
Have discharge
Itchy
Other
Eyes Other:
*
How is your pet's weight?
*
Normal
Increased
Decreased
How is your pet's thirst?
*
Normal
Increased
Decreased
None
How is your pet's mouth?
*
Normal
Bad breath
Bad teeth
Drooling
Foaming
Other
Mouth Other:
*
How is your pet's ears
*
Normal
Dirty
Smelly
Itchy
Other
Ears Other:
*
How is your pet's skin and coat?
*
Itchy
Rash
Flakey
Greasy
Other
Skin & Coat Other:
*
How is your pet's respiration?
*
Normal
Coughing
Congested
Panting
Shallow
Heavy
Other
Respiration Other:
*
How is your pet's urination?
*
Normal
Increased
Decreased
Bloody
None
Other
Urination Other:
*
How is your pet's stool?
*
Normal
Diarrhea
Constipated
Bloody
Other
Stool Other:
*
How is your pet's disposition?
*
Normal
Lethargic
Seems in pain
Disoriented
Other
Disposition Other
*
Has your pet had any:
*
Vomiting
Sneezing
Nasal discharge
Coughing
Not Applicable
Other concerning symptoms not listed:
*
I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet described above. I authorize the doctor and assistants to perform the procedure(s) listed above, including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the pet. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made and assume full financial responsibility.
I agree to hold Cheyenne West Animal Hospital harmless, in the absence of negligence, from and against any and all liability arising out of the performance of any of the procedure(s) referred to above. I have been informed that Cheyenne West Animal Hospital is not staffed 24 hours a day. I understand that if my pet requires overnight supervision post-surgically, or hospitalization, my pet will be referred to the appropriate emergency hospital.
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