Phone Number *
Email Address *
Authorized Party's Name *
Authorized Party's Relationship To You *
Pet’s Name *
Species (Dog, Cat, Other) *
Breed *
Age / Date of Birth *
Approximate Weight (If Known)
What is your primary concern today? *
When did the problem start? *
How is your pet's energy level? *
How is your pet's appetite? *
When did the vomiting start? *
How often is your pet vomiting? *
What does the vomit look like (food, bile, foam, blood, foreign material)? *
When did your pet last eat? *
Was the food kept down? *
When did your pet last drink? *
Was the water kept down? *
Has there been any recent diet change? *
Has your pet had access to garbage, toxins, unusual foods, plants, bones, toys, socks, corn cobs, string, or other foreign objects? *
How is your pet acting? (normal, lethargic, hiding, painful, restless) *
Is your pet still interested in food? *
When did the diarrhea start? *
How many bowel movements per day? *
Is there blood or mucus in the stool? *
If blood is present, is it bright red or dark/black? *
Is your pet straining to defecate? *
Has your pet had any recent diet changes? If yes, what changed and when? *
Has your pet gotten into garbage, table food, or anything unusual? *
Is your pet vomiting, lethargic, or eating less than normal? *
When did the itching start? *
Where is your pet itching, licking, chewing, or scratching? *
Is the itching seasonal or year-round? *
Any hair loss, redness, odor, or rash? *
Are any other pets in the household itching? *
What flea/tick prevention is your pet currently on? *
When was the last dose given? *
Have there been any recent changes in food, treats, supplements, shampoos, detergents, bedding, or environment? *
When did you first notice the problem? *
Is there odor, discharge, redness, swelling, or pain? *
Is your pet shaking its head or scratching at the ears? *
Has your pet had previous ear infections or treatments? *
What flea/tick prevention is your pet currently on? *
When was the last dose given? *
When did the first seizure occur? *
How often do seizures occur? *
How long does a typical seizure last? *
How long does it take your pet to return to normal afterward? *
Is your pet currently taking seizure medication? *
Has your pet missed any medication doses recently? *
Could your pet have had access to rat poison? *
Could your pet have had access to medications, recreational drugs, toxins, or marijuana products? *
When did the coughing start? *
Is the cough dry/hacking or wet/productive? *
Is it worse with exercise, excitement, pulling on the leash, or at night? *
Any breathing difficulty? *
Any nasal discharge? *
Any decrease in energy? *
Any exercise intolerance? *
Any collapse or fainting episodes? *
Is your pet currently taking any heart, airway, or respiratory medications? *
Has your pet recently visited a dog park, groomer, kennel, daycare, boarding facility, or training class? *
Does your pet have a history of heart disease? *
When did the problem start? *
Is your pet straining to urinate? *
Is your pet urinating more frequently? *
Is there blood in the urine? *
Any accidents in the house? *
Any increase in drinking water? *
Has your pet had previous urinary tract problems, stones, or infections? *
When did the problem start? *
Was there a known injury? *
Is your pet able to bear weight on the leg? *
Have you noticed swelling? *
Any medications given at home? *
Has your pet had previous orthopedic injuries or surgeries? *
When did the problem start? *
Is your pet squinting? *
Is there discharge? If yes, what color? *
Is the eye red? *
Does the eye appear cloudy or blue? *
Has there been any trauma or injury? *
Have you noticed any vision changes? *
Where and when? *
Current medications and supplements (include doses if known): *
Any recent diet changes? *
Any possible toxin exposure (medications, marijuana, rat poison, chemicals, plants, etc.)? *
Any recent travel? *
