Lake City Pet Hospital Curbside General History Form

Client (human) Name *

First Name Last Name

Client Email *

example@example.com

Primary Phone Number (Please enter the best number to reach you at on the day of your appointment. We will need to contact you before any treatments can be performed.) *

Area Code Phone Number

Secondary Phone Number (because we will be needing to communicate with you by phone, an additional phone number is needed in case we cannot reach your primary number) *

Area Code Phone Number

Emergency Phone Number

Area Code Phone Number

Appointment Date (if you haven't scheduled yet, please call or text us at 208.664.5629) *

Date

Pet Name *

Pet Species *

Dog Cat

Pet Breed

Pet's approximate age or DOB *

Is your pet spayed/neutered? *

Yes No I don't know

Is your pet current on their vaccines? *

Yes No I don't know

Has your pet been seen by another veterinarian? If so, when and where? *

Why are we seeing your pet today? *

General wellness or booster exam (with or without vaccines) Rechecking a health concern that has been previously diagnosed I have a new health concern (please describe below)

If you have a health concern, please describe below. How long has it been going on? Is it improving, getting worse, staying the same? If you have no concerns, write "none." *

Is your pet on a pet insurance plan? *

Yes No No, but please tell me more!

Where does your pet go (check all that apply and include places they may go within the next year)? *

Please list any prescription or OTC medications, diets, supplements, vitamins, heartworm/flea/tick meds, etc that your pet is currently taking or has taken in the last 60 days. Type "None" if they are not taking anything. *

Does your pet have any current/ongoing health issues and/or any allergies or sensitivities? *

Yes (describe below) No

If yes, please list below.

What food are you feeding your pet (include kibble, canned, table scraps, homecooked, treats, etc)? List brands/flavors if at all possible. Also list things they tend to eat that they are not supposed to (trash, wildlife, toys, feces, etc). *

How often do you feed your pet? *

How much (quantity) do you feed your pet per feeding? *

Is your pet eating? *

Yes, they are eating normally. Yes, and they are eating more than usual. Yes, but not as much as usual. Yes, but only small amount and/or with coaxing. No, they are not wanting to eat.

Is your pet drinking water? *

Yes, they are drinking their normal amount. Yes, they are drinking more than usual. Yes, but not as much as usual. Yes, but only small amount and/or with coaxing. No, they are not drinking.

Is your pet vomiting? *

Yes, they are vomiting or have recently. No, there has been no recent vomiting.

If yes, describe how often they are vomiting, what it looks like, and when it occurs (after eating, drinking, exercising, all the time, etc).

Describe your pet's recent urination habits (select all that apply). *

Normal amounts and frequency. Urinating less often. Urinating more often. Urinating in new/inappropriate places. Urine looks/smells abnormal.

If abnormal, please provide any additional information.

Describe your pet's recent bowel movements (select all that apply). *

Normal appearance and frequency. Loose Watery Bloody Dark Tarry Mucoid (mucus) Less frequent than usual My pet is not producing bowel movements.

Does your pet seem painful? *

Yes No Unsure

If yes or unsure, describe below.

Is your pet coughing and/or sneezing (check all that apply)? *

No Coughing Sneezing

Is there any addition information that would be helpful (more details about answers above, behavioral concerns, helpful hints on handling your pet, particular triggers your pet may have, etc)?

If your pet has been seen at another facility that we do not already have records from, please provide the name(s) and locations of those clinics so that we can request their records. This will ensure that we have all the information needed to appropriately care for your pet.

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of your pet's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Although we may not anticipate any issues, because you will not be onsite for any/all treatment, please indicate your wishes below in the event of any cardiac and/or respiratory arrest while your pet is with us today. *

I agree to CPR being performed in case of arrest. I elect a “Do Not Resuscitate” status in case of arrest .

Fine Print: I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. By entering my name below, I certify that I am over eighteen years of age. I understand that as part of Lake City Pet Hospital's desire to keep my pet's visits as fear free as possible, if my pet shows signs of elevated fear and/or anxiety, they may receive an anti-anxiety and/or sedating medication at the discretion of the doctor unless I specifically request otherwise. There may be an additional cost of up to $30 for this service. I authorize and direct the veterinarian and designated staff of Lake City Pet Hospital to receive, treat, medicate, and perform diagnostic and/or therapeutic procedures as discussed and provided in the estimate. If no estimate has been provided, I authorize a comprehensive exam (cost is $60) to be performed in order to generate an estimate. The purpose of the hospitalization and the proposed treatment plan have been clearly explained to me. I understand that no guarantee of successful treatment outcome can be given and that the patient's condition may improve or decline during the period of hospitalization despite appropriate medical care and monitoring. I understand that unexpected reactions to medications can occur. If I have any questions about the potential risks, I have discussed them with the staff before hospitalizing my pet. If further care is needed after business hours (Monday-Friday 8:00am-5:30pm) or on holidays, I understand that transfer of care to Emergency Pet Care is recommended. Patient transport to and from the emergency clinic as well as any additional cost incurred during the stay are my responsibility. In the event that transfer to the emergency clinic is not a possibility, I understand that the patient will only receive intermittent monitoring and that unexpected and serious complications may develop during this period. I agree to pay in full at time of service for all services performed, including those deemed necessary for medical/surgical complications or otherwise unexpected circumstances. I have read and understand this authorization and hereby accept and agree to the terms of the consent for hospitalization and/or treatment. *

Type your full name to agree to the above statements.