Name *

First

Last

Pet's Name *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Primary Phone *

Secondary Phone

Email *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Who will be dropping off your pet?

Me
Someone else

Name *

First

Last

Primary Phone *

Secondary Phone

Car make, model, and color that you will arrive/arrived in *

Species *

Dog
Cat

Reason for visit (check all that apply) *

Surgical/ Dental procedure
Non-Surgical Sedation Procedure
Other Procedure/ Testing

If other, please explain *

Are there any concerns for (check all that apply) *

Has your pet's eating increased or decreased? *

Increased
Decreased

Eating concerns – please explain *

Eating concerns – when did this issue start? *

Has your pet had eating issue in the past? *

Yes
No

If yes, when? *

Has your pet's drinking increased or decreased? *

Increased
Decreased

Drinking concerns – please explain *

Drinking concerns – when did this issue start? *

Has your pet had drinking issue in the past? *

Yes
No

If yes, when? *

Bad breath concerns – please explain *

Bad breath concerns – when did this issue start? *

Has your pet had bad breath issue in the past? *

Yes
No

If yes, when? *

Excessive sleeping/lethargy concerns – please explain *

Excessive sleeping/lethargy concerns – when did this issue start? *

Has your pet had excessive sleeping/lethargy issue in the past? *

Yes
No

If yes, when? *

Weight loss concerns – please explain *

Weight loss concerns – when did this issue start? *

Has your pet had weight loss issue in the past? *

Yes
No

If yes, when? *

Weight gain concerns – please explain *

Weight gain concerns – when did this issue start? *

Has your pet had weight gain issue in the past? *

Yes
No

If yes, when? *

Itching/scratching/hair loss concerns – please explain *

Itching/scratching/hair loss concerns – when did this issue start? *

Has your pet had itching/scratching/hair loss issue in the past? *

Yes
No

If yes, when? *

Difficulty standing up concerns – please explain *

Difficulty standing up concerns – when did this issue start? *

Has your pet had difficulty standing up in the past? *

Yes
No

If yes, when? *

Scooting concerns – please explain *

Scooting concerns – when did this issue start? *

Has your pet had scooting issues in the past? *

Yes
No

If yes, when? *

Shaking head concerns – please explain *

Shaking head concerns – when did this issue start? *

Has your pet had shaking head issues in the past? *

Yes
No

If yes, when? *

Car sickness concerns – please explain *

Car sickness concerns – when did this issue start? *

Has your pet had car sickness in the past? *

Yes
No

If yes, when? *

Vomiting concerns – please explain *

Vomiting concerns – when did this issue start? *

Has your pet had vomiting issues in the past? *

Yes
No

If yes, when? *

Diarrhea/abnormal stools concerns – please explain *

Diarrhea/abnormal stools concerns – when did this issue start? *

Has your pet had diarrhea/abnormal stools in the past? *

Yes
No

If yes, when? *

Skin masses/lesions concerns – please explain *

Skin masses/lesions concerns – when did this issue start? *

Has your pet had skin masses/lesions in the past? *

Yes
No

If yes, when? *

Urination concerns – please explain *

Urination concerns – when did this issue start? *

Has your pet had urination issues in the past? *

Yes
No

If yes, when? *

Sneezing concerns – please explain *

Sneezing concerns – when did this issue start? *

Has your pet had sneezing issues in the past? *

Yes
No

If yes, when? *

Coughing concerns – please explain *

Coughing concerns – when did this issue start? *

Has your pet had coughing issues in the past? *

Yes
No

If yes, when? *

Eye concerns – please explain *

Eye concerns – when did this issue start? *

Has your pet had eye issues in the past? *

Yes
No

If yes, when? *

Difficulty breathing concerns – please explain *

Difficulty breathing concerns – when did this issue start? *

Has your pet had difficulty breathing in the past? *

Yes
No

If yes, when? *

Lameness/painful limp concerns – please explain *

Lameness/painful limp concerns – when did this issue start? *

Has your pet had lameness/painful limps in the past? *

Yes
No

If yes, when? *

Do you have any specific questions for the doctor today?

What kind of food are you feeding your pet? *

How often do you feed your pet? *

Has your pet had any other food but their own? *

Yes
No

If yes, what? *

When did your pet last eat? *

When did your pet last drink? *

Is your pet currently taking any medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Has your pet ever had an adverse reaction to a medication? *

Yes
No

If yes, please explain *

Is your pet on heartworm prevention? *

Yes
No

If yes, please list medication & last dose *

Please note: If your pet has fleas, they will be given a Capstar at your expense.

Do you need a refill today? *

Yes
No

Is your pet on flea and tick prevention? *

Yes
No

If yes, please list medication & last dose *

Do you need a refill today? *

Yes
No

Is it okay to sedate your pet/put your pet under anesthesia if necessary (understand there are always inherent risks, including death)? *

Yes
No

In order for our doctors to do a complete analysis for diagnosis; do we have permission to perform the following if needed?

Please note: Pre-anesthetic bloodwork checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform bloodwork prior to anesthesia or sedation.

CPR Consent: I, the owner/agent understand that the therapeutic, anesthetic, or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s), staff, and New Richmond Veterinary Clinic conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. We will administer CPR treatment unless declined. *

Accept
Decline

Estimates

I received an estimate and understand it is a best case estimation of charges and unexpected charges could occur.
I decline an estimate and agree to pay all incurred fees without the prior estimate of costs.

I, the owner/agent for the pet described above, request and authorize an exam for my pet. I understand that the staff at New Richmond Veterinary Clinic will contact me at the number listed above after my pet has been examined to discuss diagnosis and treatment and will have an initial estimate of charges.

I understand 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.

Signature *

Date *

Surgery Consent Form

New Richmond Surgery Consent Form

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