Southwest Plaza Animal Clinic
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Client Name: _________________ Patient # (Office use only) : _________
Pet Name: _________________ Today's Weight: _________
Number where you can be reached today: (____)________________________
Alternate Number: (____)________________________

Please check all symptoms that apply to your pet:

Straining to urinate: _____ Panting: _____ Odor: _____
Frequent urination: _____ Vomiting: _____ Difficulty breathing: __
Constipation: _____ Coughing: _____ Hair loss: _____
Diarrhea: _____ Watery Eyes: ____ Restlessness: _____
Decrease in water intake: _____ Lethargic: _____ Scooting: _____
Increase in water intake: _____ Depressed: _____ Gagging: _____
Decrease in appetite: _____ Weakness: _____ Seizures:
Increase in appetite: _____ Limping: _____ Shaking head: _____

Discharge: Where? _________ Color? ________ For how long? ________
Pain: Where? __________________________ For how long? _________
Growths: Where? ________________ When did you notice them? ______
Behavioral Changes: Since when? _____________________________
What are they? _____________________________________________

If you have noticed diarrhea, how often are you noticing it? Since what date? Color and consistancy?
_______________________________________________________

If you have noticed vomiting, how often are you noticing it? Since what date? Color and consistancy?
_______________________________________________________

When did your pet last eat well? _________________________________

When did your pet last drink well? _______________________________

What does your pet's diet usually consist of? (Please be specific and include any treats, table scraps, ect.)
_______________________________________________________

What brand of food are you feeding? ______________________________ Canned or dry? ________________________
How often are you feeding your pet? _________ What amount? _________

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We have arranged for you to leave your pet here, to allow the Veterinarian to examine your pet as soon as possible. The Veterinarian will preform a thorough physical exam as soon as the schedule allows. For the benefit of your pet's health, it is important to start treatment as soon as possible. If reccomended, which procedures to you authorize?

Diagnostics Treatments
Bloodwork (Approx. $20-$85): _______ Fluid Therapy (Approx. $20): _______
Radiographs (Approx. $81): _______ Sedation (Approx. $45-$90): ______
Urinalysis (Approx. $25-$45): ______ Medication (Price varies): ______
Cytologic evaluation (lumps, bumps, ears) (Approx: $16-$85): _______
Other diagnostics and/or treatments: _______

Please inital here if you would like to be contacted prior to any treatments or diagnostics: _______

I am the owner/agent for this pet, and I authorize and request an exam for my pet. I understand that payment is due when my pet is discharged. I accept financial responsibility for charges incurred for this pet. I understand that I will be charged for flea medication if evidence of fleas is found on my pet.

Signature: _________________________ Date: ______________