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

At what number can they be reached today? *

Reason for visit: (check all that apply) *

Illness
Injury
Other

If Other, please describe:

What symptoms has your pet been experiencing?

Are there any concerns for the following: (check all that apply)

Where are the skin masses located?

If Other, please explain:

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them?

No change
Worsened
Improved

Has your pet experienced this problem in the past? *

Yes
No

If Yes, please elaborate:

Has your pet had any exposure to toxins (cleaners, chemicals, etc.) or drugs/medications (prescription, OTC, recreational)? If yes, give details below.

Does your pet have any pre-existing medical conditions we should be aware of (e.g., seizures, heart disease, kidney disease, etc.)

Is your pet on any medications? *

Yes
No

If Yes, please specify which medications, dosing, and last time of administration

What kind 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?

Have there been any changes in appetite? *

Increased
Decreased
No change

If there has, for how long? Please elaborate. *

Any increase or decrease in water consumption? *

Increased
Decreased
No change

Any change in bowel movements? *

Yes
No
Unsure

If yes, please explain *

If unsure, please elaborate *

Does your pet spend time outside, even for walks or in the yard? *

Yes
No

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

Indoor only
Indoor/Outdoor
Outdoor only

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

If Other, please explain: *

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

Yes
No

Please explain:

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? *

Once the doctor has completed your pet’s exam, we will contact you to go over the recommended treatment plan.

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

Many of our patients love peanut butter as a snack while visiting our office, but if you or your pet have an allergy to peanut butter, please let us know.

Can your pet have peanut butter? *

Yes
No

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.

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 *

Medical Concern History Form

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