Griffith Small Animal Hospital

1
Date
Yes-Up to $ ( Mention Below )
No
Please call first
Do you authorize labwork if needed?
Yes-Up to $ ( Mention Below )
No
Please call first
Do you authorize X-rays if needed?
Yes
No
Do you wish for an estimate to be made before services are rendered?
2
Please Mention Amount
$
3
Please Mention Amount
$
4
Client Name
Patient Name
Best Contact number
Secondary Contact number
Phone Call
Text
How would you prefer to be contacted by
Email
Reason for your visit today
5
(no pain)
0
1
2
3
4
5
6
7
8
9
10
(worst pain)
Please indicate your pet’s level of discomfort today
How long have you noticed these symptoms?
Frequency?
Are these symptoms improving, getting worse, or the same?
Vomiting / Retching
Diarrhea
Coughing
Sneezing
Nasal Discharge
Difficulty Breathing
Stiffness
Limping/Lameness
Shaking / Wobbly
Shaking Head
Change in attitude or behavior
Skin / Hair / Coat Changes
Excessive Licking/Chewing/Itching
Other
Have you noticed any of the following symptoms?
6
Explain
7
Growths or Lumps (Use Chart Below)
8
9
Increased
Decreased
No change
Appetite
Increased
Decreased
No change
Water consumption
Increased
Decreased
No change
Activity Level
What medications or supplements do you give your pet?
Yes
No
Has your pet been given any medications today?
10
If so, which one(s) and at what time?
11
Yes
No
Is your pet on Heartworm medicine?
Yes
No
Has your pet been fed today?
Yes
No
Do we need to feed your pet?
Indoor only
Indoor/Outdoor
Outdoor only
Does your pet stay
What type of food (Brand and Can or Dry) and frequencydo you feed your pet?
12
Is your pet allergic to any medications?
Yes
No
Do you need any medication refills?
Medication Name
We STRONGLY recommend all Dogs & Cats be on a monthly heartworm preventative
Should be Empty: