Patient History Form for Technician Appointments

"*" indicates required fields

*** At this time we are only seeing curbside and drop off appointments *** We are offering curbside appointments with the options of: Phone Call (speakerphone during the exam) Video Chat via the website doxy.me (link will be provided) Drop off appointments will be contacted via phone after the exam

Please fill out the name, phone number, and email address of the person we will be contacting during the appointment time. It is imperative that you be available to discuss and approve/decline treatments while your cat is in our care. The patient history form is required for all office visits.

Please list as medication name, dosage, directions for use, and when it was last given (Ex. Cerenia 16mg – 1/2 tab every 48 hours – Last given: 1/2/21 at 5pm)

COVID-19 Procedures

Due to the COVID-19 prevalence, we want to ensure your safety and that of our team. Please answer yes/no to these questions:

*Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.

Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough or difficulty breathing?


Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?


Curbside / Drop Off Consent

I am the owner or agent of the cat named above and have the authority to execute this consent. I understand that during the performance of
procedure(s)/operation(s), unforeseen conditions may be revealed that necessitates an extension of the foregoing procedure(s)/operation(s) or different procedure(s)/operation(s) than those provided in the treatment plan. I hereby consent to authorize the performance of such procedure(s)/operation(s) as are necessary and desirable in exercise of the veterinarian’s judgement. I have been advised as to the nature of the procedure(s)/ operation(s) and the risks involved. I realize that the results cannot be guaranteed. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. To prevent the spread of infectious disease, any cat with fleas will be treated with an oral and/or topical medication upon admission to the hospital. The price of the treatment will be added to your invoice. I have read and understand this authorization and consent. By submitting this form I hereby consent and authorize the performance of the procedures that I have approved in the treatment plan. I agree to pay all charges incurred when my cat is released from the hospital.
Please initial below if you have read the above and authorize the performance of the estimated treatments/procedures
*

This field is for validation purposes and should be left unchanged.