Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.
We now offer in-person visits to fully vaccinated individuals (final COVID vaccine administered at least 14 days prior to the appointment). Please bring your proof of vaccination or Excelsior Pass with you to the visit. We ask that only one fully vaccinated adult be present at your pet’s exam since our exam rooms are too small to accommodate many people. We encourage the use of masks and ask that you provide emotional support for your pet while a patient handler provides physical support.
The check-in and check-out processes will still occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!

Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

What is the name and phone number of the contact who will make medical decisions today? *

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

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?

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:

Do you do any dental care at home (tooth brushing, dental chews, etc.)? If yes, give details below.

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure, such as tenderness or upset stomach after vaccines? *

Yes
No

Please explain:

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

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?

Cough
Shortness of breath
Fever
Sore throat
Chills
Muscle pain
Headache
New loss of taste or smell

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

Yes
No

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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