Animal Clinic Pet Check-In Form

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Easton Commons Animal Clinic Pet Check-In
Owner's Name:___________________Pet's Name:____________________Date:___________
Please initial the services to be performed during today's visit
_____ Physical Exam
_____Vaccinations
_____ Heartworm Test
_____ Leukemia/FIV Test
_____ Fecal Exam
_____ Blood Profile
_____ Urinalysis
_____ Xray
_____EKG
_____Ultrasound
_____ Laser Therapy
_____Surgery
_____Dental Cleaning
_____ Full Groom
_____Shampoo (Regular Shampoo or Medicated) _____Brush Teeth
_____ Bath
_____ Nails (Regular or Grind)
_____ Ear Cleaning
_____ Anal Glands
If your pet is NOT well, please thoroughly complete the following list by marking all that apply:
_____ No Appetite/Decreased appetite How Long?______________
_____ Listless/Lethargic
How Long? _____________ _____ Increased Thirst
How Long?
_____ Increased Urination
How Long? _________
_____ Blood in urine How Long?
_____Diarrhea:
Blood
Liquid
Projectile
Cow patty
How Long? ______________
_____Vomiting:
Blood
Food
Bile
Foamy
How Long? ______________
_____ Coughing: Dry/Harsh Productive/Wet
How Long? _______________
_____ Sneezing:
Discharge
Color of discharge:
How Long?
_____ Eyes:
Red
Draining
Right Eye Left Eye Both
How Long?________________
_____ Scratching/Excessive licking/chewing
Where?____
How long?___________
_____ Shaking Head: How Long?_________
Ears: Scratching Discharge Odor
How long?___________
___Limping:
Which Leg?
RF
RR
LF
LR
How Long? _______________
What happened to cause limping?_____________________________________________________
Medications/Supplements:________________________________________________________________
Current Diet:__________________________________
_____ Gets Table food (cheese, bread, lunch meat, pizza, etc) regularly or occasionally
Comments/Other:_____________
_
Please verify that the above information is correct. ALL FEES ARE DUE AT THE TIME OF DISCHARGE
Additional diagnostics may be required to aid the doctor in making a diagnosis and plans for treatment. Treatment will
be delayed if you are not available for the call. Please give your authorization below:
_____Proceed with diagnostics as deemed necessary by the veterinarian’s professional judgment up to $600.00.
_____Do only minimum diagnostics needed for a diagnosis. Call if diagnostic charges would exceed $400.00.
Preferred Method of Contact:
Email:________________________
Phone_______________
Owner's Signature: ___________________________
Admitting Staff Member_________________ Time__________ AM PM

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