Client Name*

First Last

Date of My 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?*

Select all that apply*

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

Describe*

Include when it started

It has...*

Worsened
Improved some
Stayed the same

When did this happen?*

Would you like us to...*

**Please note that if we have not seen your pet before, we will need to be able to contact you regarding your pet’s examination prior to instigating any treatments.

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.

What is the best number to contact you at today?*

Pet Illness Medical History Form

APPOINTMENTS

HOSPITAL HOURS

CONTACT US

DIRECTIONS