Enter your First and Last name*

Enter your pets name here*

Enter email*

Phone Number*

Appointment Date*

Reason for your pets visit (Main Symptoms)*

How long has your pet been experiencing these symptoms? (Required)

How is your pets appetite? (Required)

How is your pets water intake? (Required)

Is your pet lethargic? (Required)

If your pet is a cat, does your cat go outdoors? (Required)

Have you tried any at home treatments? If so, what? (Required)

Have you noticed any blood in your pets urine? (Required)

Is your pet having urinary accidents in the house? (Required)

Is your pet experiencing more frequent urination? (Required)

Is your pet straining to urinate? (Required)

Is your pet lame/limping? If so, which leg? (Required)

Is the limp...

Are your pets eyes bothering them? If so which eye? (Required)

Is there discharge from the eye? If so, please describe. (Required)

Is your pets eye red or irritated? (Required)

Are your pets ears bothering them? If so, which ear? (Required)

Is your pet itchy? (Required)

Is your pet losing fur? (Required)

Have you bathed your pet recently? If so, with what? (Required)

Have you seen any fleas or ticks on your pet recently? (Required)

Are there any upper respiratory symptoms such as coughing, sneezing, etc.? (Required)

If bathing/clipping would be beneficial, do we have permission? (Required)

Do we have permission to do lab tests, if indicated? (Required)

Do we have permission to do x-rays, if indicated? (Required)

Do we have permission to sedate in required? (Required)

Do we have permission to begin treatment? (Required)

Please list any other patient history or information needed regarding your pet and your pets illness.