Name* Phone*Alternative PhoneHas your address or email changed since the last visit? If so, write it here: Pet's Name* On heartworm prevention?* Yes No What kind? On flea prevention?* Yes No What kind? What food does your pet eat?* Any supplements/people food?* Has your pet had any medical concerns in the past / any history of illness besides conditions we have treated him/her for? If so, please explain:*Does your pet spend time outdoors where wildlife live (for instance access to creeks, lakes, roaming outdoors, camping)* Yes No Does your pet go to a groomer or boarding facility or do you work or volunteer in a grooming/boarding/kennel facility?* Yes No Are there any people in contact with this pet who are immunosuppressed?*Is your pet friendly with strangers? If no, provide details of what sort of situations he/she is not friendly in* Yes No If no, provide details here Primary Concern Today* Duration of symptoms Getting better/worse? How is your pet feeling?* Normal Slightly lethargic Very lethargic/weak Appetite* Normal Decreased Not eating at all Please put how long your pet has decrease appetite or how long is your pet not eatingDrinking/urination* Normal Decreased Increased Please put how long your pet has increased or decreased urinationAny vomiting?* Yes No Specify how many times/how many daysAny diarrhea?* Yes No Specify how many times/how many daysAny coughing, sneezing, or nasal discharge in the past two weeks? If yes, describe* Yes No If yes, please describeHas your pet had a similar problem in the past?* Yes No Please list all the medications you are currently giving your pet and how frequently you are giving them. Please list even if you were prescribed them by us as we want to confirm your pet is still receiving them. Please note if your pet has missed any doses within the past week and when it was missed. List the times you last gave each medication. (example: Furosemide 12.5 mg 1 tab once daily, last given at 8am today, one dose missed yesterday morning)We recommend all pets both young and old have at least annual bloodwork ran to obtain a baseline of each pet's normal levels of organ function. Would you like us to run bloodwork on your pet today? Yes No Is there anything else we need to know?*Please note: We will do an examination and basic testing/medications (such as giving pain meds to a painful pet) and then Dr. Jordan will give you a call to discuss the treatment plan. Typically the cost of the initial exam, tests, and meds is $100-250. If it is over $250, we will call you to discuss prior to performing tests/treatments. Once we have completed tests and treatments, we will call you and set up a pick up time. We will take payment at that point over the phone. Do you have any questions or concerns?Do you have any other pets (that you haven’t told us about) that are NOT patients of Crossroads Animal Hospital? If yes, what is their age, breed, and current vet?PhoneThis field is for validation purposes and should be left unchanged.
