Veterinary Outpatient Form

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Outpatient Form
Personal Information
Owner Name:
Pet Name:
Date:
Breed:
Colors:
Markings:
Sex:
Neutered?
DOB:
Age:
Owner Phone No.:
Cell No.:
Vet History
Reason For Visit:
Pet’s First Visit?
Reason For Other Visits:
Regular Vet:
Phone:
Immunizations Current?
Last Updated:
Shots Required:
Current Medication:
Allergies:
Food Type Given to Pet:
Last Fed:
Symptoms (Check All That Apply)
Coughing
Diarrhea
Ear Odor/Discharge
Eye Odor/Discharge
Lethargy
Lesions
Limping
Scratching
Sneezing
Bloody Urine
Difficulty Urinating
Increased Urine
Vomiting
Weight Gain
Weight Loss
Other Symptoms:
If pet is limping, which leg?
If pet is scratching, where?
Duration of Symptoms:
Frequency of Symptoms:
I, the pet’s owner, consent and authorize the pet to be examined and diagnosed by the veterinarian, who
will then call me at my phone number listed above in order to discuss solutions and procedures. If my pet
has fleas, ticks or mites I understand that I will be charged with the cost of removing them. I swear and
attest that my pet’s vaccinations are current and that all of the information listed above is true to the best of
my knowledge.
Signature
Date

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