Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Who should we contact to make medical decisions today? *

First

Last

Would you like to accompany your pet into the clinic today, or would you prefer a curbside visit and a call from the veterinarian? *

In-person visit
Call

At what number can they be reached today? *

Reason for visit: (check all that apply) *

Annual Physical
Heartworm/Tick test (dogs)
Fecal/intestinal parasite screen
Deworming treatment
Annual physical - unsure of other services that are due. Would like to discuss with veterinarian.
Vaccines

Other procedures: (All procedures at additional cost)

Anal glands
Ear cleaning

Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply)

Any other pertinent medical history? *

No
Yes

If Yes, please explain:

Where are the skin masses located?

If Other, please explain:

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

Yes
No

If Yes, please elaborate: *

What brand and type of food do you feed your pet?

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

How much is given during each feeding and how many feedings per day?

Do you have insurance for your pet? *

Yes
No

If yes, what insurance?

Do you give your pet heartworm or flea/tick preventative? *

Yes
No

Please specify product(s) and date last given *

Do you wish to take home flea/tick/heartworm prevention today? *

Yes
No
Unsure, speak with a veterinarian about recommendations for my pet

Flea/Tick/HW prevention:

Simparica TRIO (monthly oral flea, tick, and heartworm prevention for puppies over 8 weeks and adult dogs)
Revolution PLUS (cats)
MilbeGuard (heartworm prevention for dogs)
Simparica (monthly oral flea/tick prevention for dogs)
Seresto collar (dogs or cats)
None

For cats: Is pet indoor only, indoor/outdoor, outdoor only?

Indoor only
Indoor/Outdoor
Outdoor only

What percentage of time does your pet spend outside?

Have you seen any fleas or ticks on your pet? *

Yes
No

Please specify - fleas or ticks?

Do you have other pets? *

Yes
No

Are they currently vaccinated and on heartworm and flea prevention? *

Yes
No

Does your pet come into contact with other dogs? Please check all that apply *

If Other, please explain:

Is your pet on any medications? *

Yes
No

If Yes, please list all medications (prescribed or over the counter) and the time of last administration:

Do you do any dental care at home (tooth brushing, dental chews, etc.)? If yes, give details below. *

Was your pet last seen by a veterinarian at Russell Lake Animal Hospital? *

Yes
No

Is your pet’s Rabies vaccine up to date? *

Yes
No

When is the last time your pet was seen by a veterinarian? *

Who was your pet’s previous veterinary clinic? *

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Russell Lake Animal Hospital authorization to treat as discussed above. *

I have read and agree

Appointments: Please arrive a few minutes early or on time to check in. Late arrivals may not be accommodated and a late fee of $50 may be applied to your account. Once the exam has been performed and a plan has been discussed we will proceed with providing treatment. *

I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Yes
No

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet. *

I agree
I disagree

Please type your initials. *

Date *

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