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? *

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

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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