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)

**Please wear a mask covering your nose and mouth while interacting with our team. We ask that only two masked people be present at your pet’s exam.

Who should we contact to make medical decisions today? *

First

Last

At what number can they be reached today? *

How has your pet been since the previous appointment for this concern? *

Better
Worse (please elaborate)
No change noted at home

Please elaborate: *

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

Any other pertinent medical history? *

No
Yes

If Yes, please explain:

Has your pet's eating: *

Increased
Decreased
Not eating at all

Please explain *

Has your pet's drinking: *

Increased
Decreased
Not drinking at all

Please explain *

Where are the skin masses located?

If Other, please explain:

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

Yes
No

If Yes, please elaborate: *

Is your pet on any medications? *

Yes
No

If Yes, please elaborate - list medications are still being given, and last time administered *

Do you need any of the following for Flea/Tick/HW prevention: *

Yes
No

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

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 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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