Name: Russell Lake Animal Hospital
Address: 19 Norm Newman Dr., Dartmouth, NS, B2W 6M3, Canada
Telephone: 902-407-4570
Price range: $

Owner Name *

First

Last

Phone *

Email *

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? *

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/date of birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

When did you get your pet? *

Where did you get your pet? *

If other, please specify *

What kind of food do you feed your pet? *

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount

Measured amount *

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

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

If other, please specify *

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

Yes
No

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: *

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

I understand

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

I authorize

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days? *

Yes
No

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Who experienced these symptoms?

Self
Someone else in the house
No symptoms

*If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment.*

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. We ask that you remain masked while in the examination room. Once the exam has been performed and a plan has been discussed and approved with the veterinarian. *

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 *

Please text photos of your pet's records to 902-407-4570 and/or bring any paperwork with you to the appointment so that your veterinarian knows which vaccines or treatments have already been started.

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