Palisades Veterinary Hospital - Early Drop Off Exam Questionnaire

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* This field is required.
Client Name
Patient Name
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Reason for today’s visit
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When did the problem start?
4
Is this a new problem or a reoccurring problem?
New
Old
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Are there any other concerns you would like addressed?
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Diet
What food are you feeding?
How much do you feed?
How often do you feed?
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What kind of treats / snacks / table scraps / chews do you give your pet?
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Any recent changes in diet?
Yes
No
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If yes, please explain
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Current medications/supplements?
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Any known allergies/medication sensitivities?
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Has your pet been seen elsewhere for medical care since we last saw him/her?
Yes
No
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If yes, when?
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Please Select
Please Select
Yes
No
May we request records?
Where?
What was done?
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Does your pet have any of these symptoms?
Coughing
Sneezing
Vomiting
Diarrhea
Excessive drinking
Excessive urination
Increased or decreased appetite
Other
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If other, please specify
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I agree to and understand this policy
I authorize the Doctors and staff at Palisades Veterinary Hospital to provide all medical and surgical treatment deemed necessary in the doctor’s professional judgment. I acknowledge that in the event that the Palisades Veterinary Hospital staff is not able to contact me immediately they are authorized to initiate appropriate treatment until I (or the pet’s agent) can be reached. I agree to pay all related expenses associated with treatment of my pet until I am available to discuss further care and related fees with the attending veterinarian. If my pet has a serious illness or injury that becomes critical during my absence, I want the doctors to
Client Initials
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Best number to be reached?
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Is there a specific time you need to pick up by?
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Verify client contact information to ensure it is current.
Name
Address
Phone
Email
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Signature* This field is required.
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