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Griffith Small Animal Hospital - Drop Off Form(Back-up)
1
Date
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Yes-Up to $ ( Mention Below )
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Please call first
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Please call first
Do you authorize labwork if needed?
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No
Please call first
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Yes-Up to $ ( Mention Below )
No
Please call first
Do you authorize X-rays if needed?
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No
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Do you wish for an estimate to be made before services are rendered?
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2
Please Mention Amount
$
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3
Please Mention Amount
$
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4
Client Name
Patient Name
Best Contact number
Secondary Contact number
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Phone Call
Text
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Phone Call
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How would you prefer to be contacted by
Email
Reason for your visit today
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5
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(no pain)
0
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10
(worst pain)
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(no pain)
0
1
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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
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?
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6
Explain
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7
Growths or Lumps (Use Chart Below)
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8
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9
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Increased
Decreased
No change
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Increased
Decreased
No change
Appetite
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Increased
Decreased
No change
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Increased
Decreased
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Water consumption
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Increased
Decreased
No change
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Increased
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Activity Level
What medications or supplements do you give your pet?
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Yes
No
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Yes
No
Has your pet been given any medications today?
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10
If so, which one(s) and at what time?
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11
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Yes
No
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Yes
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Is your pet on Heartworm medicine?
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Yes
No
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Yes
No
Has your pet been fed today?
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Yes
No
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Yes
No
Do we need to feed your pet?
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Indoor only
Indoor/Outdoor
Outdoor only
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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?
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12
Is your pet allergic to any medications?
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Yes
No
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Yes
No
Do you need any medication refills?
Medication Name
We STRONGLY recommend all Dogs & Cats be on a monthly heartworm preventative
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