Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Would you prefer to be contacted by text, email or phone call?

Text
Email
Phone call

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Full name of other person to contact for medical decisions *

First

Last

At what number can they be reached today? *

Current insulin brand/type and dose

Time last dose was given

How is your pet doing overall?

Diet and amount of food fed with timing

Is your pet getting any other treats or table food?

Yes
No

If yes, specify *

am and above

How is appetite (poor, healthy, ravenous)?

How is thirst (poor, healthy, excessive)?

Is there any vomiting?

Yes
No

How is the pet's urine production (healthy, small volumes, large volumes)?

Cats: Is your cat using the litter box appropriately?

Is there any straining to urinate?

Yes
No

Do you have any other concerns for the doctor?

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 obtain your consent and 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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