Pet Illness Medical History

Full Name * *

Date of Pet's Appointment *

Pet's Name *

Belongings

BEST phone number to reach you at *

Home Phone

Cell Phone

Work Phone

Please describe the problem(s) your pet is having, pertinent history leading up to the current condition and any previous major medical problems *

When did this start? *

What is the severity and frequency of this problem? *

What medications/supplements (if any) has your pet received in the last 24 hours? *

Please include name of medication, amount given and time given.

Any other medications or supplements usually given? *

Please include name of medication, amount given and frequency given.

When was your pet's last meal? *

What did they eat? *

My pet is lethargic *

Yes
No

My pet has lost weight *

Yes
No

My pet has gained weight *

Yes
No

My pet is urinating more *

Yes
No

My pet is urinating innappropriately *

Yes
No

My pet is losing their hair *

Yes
No

My pet is coughing *

Yes
No

My pet is drinking more *

Yes
No

My pet seems constipated *

Yes
No

My pet has a lump *

Yes
No

My pet's skin is red, itchy, bumpy etc. *

Yes
No

My pet's urine is abnormal (color, consistency) *

Yes
No

My pet has difficulty breathing *

Yes
No

My pet is vomiting *

Yes
No

My pet is having diarrhea/abnormal stools *

Yes
No

My pet has an eye issue *

Yes
No

Other Reason

If vomiting, what color? *

If diarrhea, what color? *

If diarrhea, what consistency? *

If vomiting, what substance? *

If vomiting, when was the last time they vomited?*

Has your pet had access to foods other than recommended pet foods? If yes, describe *

My pet is

Lame
Sore
Has been injured

Please provide more details including when it started:

This problem has

Worsened
Improved some
Stayed the same

When did this happen?

Recently
Long-term (chronic) problem

Would you like us to *

Treat your pet after examination. I am aware that I am responsible for all costs.
Call with the findings of the examination and an estimate of treatment cost prior to treatment.

Consent *

I am the owner/agent for the described animal; I authorize and request an exam for my pet.

I understand the veterinarians and/or staff at McPhillips Animal Hospital will contact me after my pet’s examination to discuss recommended diagnostics and treatment. If requested, all efforts will be made to reach me prior to the administration of any treatments prior to them being performed. If I cannot be reached, I authorize initial treatment, including fluid support and other supportive medications, to be started as indicated for my pet.

I understand that during the performance of the examination and potential procedures, unforeseen conditions may arise that necessitate additional or different procedure(s), operation(s), or treatment(s) than those set forth. Therefore, I hereby consent to and authorize the performance of such as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I understand and accept that when sedation and/or anesthesia are involved, there are always inherent risks including death.

The nature of the examination/diagnostics has been satisfactorily explained to me and no guarantee has been made as to the result or cure. I understand there may be risk involved in these procedures.

I understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.

I understand that payment is due when my pet is discharged; however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

I agree to the above stated.

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY * *

Pet Illness Medical History

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