Patient:Owner:Date MM slash DD slash YYYY What is the reason we are seeing your pet today?Primary Complaints: Check any that apply and describe below: Vomiting Diarrhea Eyes Lethargic Coughing Blood in stool Constipation Ears Lameness/Limping Sneezing Blood in urine Growth/Lump Itching Painful Difficulty Breathing Details on above conditions and indicate on diagram if painful, lumps or growths:Has your pet had an increase/decrease/no change in the following:(Please circle one) Drinking Increased Decreased No Change Appetite Increased Decreased No Change Urination Increased Decreased No Change Defecation Increased Decreased No Change Weight Increased Decreased No Change Did your pet eat today? Yes No If yes, please list what and the time he/she ate:Has your pet been seen by another veterinarian recently? Yes No If yes, describePlease read and initial one of the following: Please do exam, $89 (exam + hospital ward) only and call with estimate. Please perform diagnostics/procedures up to $300 until I can be contacted. Please contact me after my pet’s examination.Contact At:(Please contact me after my pet’s examination.)SignatureDate MM slash DD slash YYYY
