NON-SURGICAL/ANESTHESIA DROP OFF QUESTIONNAIRE – Veterinarians in Oviedo, Florida

Name

First Last

Email

Phone

PATIENT NAME:

APPOINTMENT DAY/TIME

WHAT IS THE REASON FOR YOUR VISIT TODAY?

HAS YOUR PET EVER BEEN EXAMINED FOR THIS ISSUE IN THE PAST?

Yes
No

If YES, were any diagnostics performed (bloodwork/x-rays)?

What was the outcome?

IS YOUR PET TAKING ANY MEDICATIONS?

Yes
No

What are the names of the medications and how often are they administered?

IS YOUR PET ALLERGIC TO ANY MEDICATIONS?

Yes
No

If YES, what are they?

AUTHORIZATION FEES

Please call me with an estimate after the examination prior to any diagnostics/treatments being performed.
I authorize TOAH to perform diagnostics/treatments up to $100
I authorize TOAH to perform diagnostics/treatments up to $200
I authorize TOAH to perform diagnostics/treatments up to $300
I authorize TOAH to perform diagnostics/treatments up to $400

Is your pet eating and drinking normally?

Yes
No

Is your pet weak or lethargic?

Yes
No

Do you feed your pet human food?

Yes
No

Is your pet vomiting?

Yes
No

Does your pet have diarrhea?

Yes
No

Have you seen your pet passing worms in its stool?

Yes
No

Is your pet urinating normally?

Yes
No

Is your pet defecating normally?

Yes
No

Is your pet coughing?

Yes
No

Is your pet sneezing?

Yes
No

Is your pet gagging?

Yes
No

Has your pet been exposed to other pets recently?

Yes
No

Do you have other dogs or cats?

Yes
No

Has your pet had seizures?

Yes
No

Does your pet have a habit of chewing/eating bedding or toys?

Yes
No

Has your pet fainted or passed out?

Yes
No

Has your pet had any surgical procedure recently?

Yes
No

Is your pet shaking its head?

Yes
No

Is your pet on Heartworm preventative?

Yes
No

Is your pet on Flea and tick preventative?

Yes
No

Is your pet limping?

Yes
No

If yes, which leg is it? LR, RR, LF, RF

Is your pet scratching and where?

Does your pet have hair loss and where?

ADDITIONAL INFORMATION

- Bring your pet in at your scheduled time, along with this competed and other required forms.
- Bring all of your pet’s medications and/or any records, radiographs, etc.
- Your pet must be picked up by 5:30 pm unless it is hospitalized.
- After the examination, we will contact you to secure a definitive pick up time.

Additional Notes for the Doctor:

Consent

We keep our hospital flea and tick free. All pets will be checked for fleas and ticks at admittance and if fleas and ticks are found they will be treated at the client’s expense. Upon discharge all pets are checked to verify that they are flea and tick free prior to our release.

Client Signature*

Date*