Date Owner First Name Owner Last Name Street Address City State Zip Home Phone Work Phone Mobile Phone Email Work Name & Address Spouse/Significant Other First Name Spouse/Significant Other Last Name Spouse/Significant Other Mobile Phone Spouse/Significant Other Work Phone Spouse/Significant Other Work Name & Address How did you hear about us? Phone BookPrintInternetReferred by FriendDrive By If referral, Name of Person
Pet Name Pet Type DogCatOther Breed Sex MaleFemale Spayed/Neutered YesNo Date of Birth Color/Markings Previous Veterinarian Relevant Medical History (Allergies, Vomiting, Diarrhea, Water/Urine changes, etc.) Is your pet on any prescription or over-the-counter medications, or any supplements? YesNo If yes, please indicate what medications/supplements and the dosage: Reason for visit to Montgomery Animal Hospital
Please note that all professional fees are due at the time the services are rendered. For your convenience, we accept cash, debit, personal checks, MasterCard, Visa, American Express and Discover.
Instructions
Please check all that apply to your dog:
Behavior / Neurologic My dog is just not acting like himself/herself.My dog is not seeking as much attention and interacts less with the family.My dog seems confused or disoriented.My dog has been barking or howling excessively for no apparent reason.My dog's sleeping patterns have changed.My dog has had tremors or episodes of shaking.My dog is slowing down.My dog has been panting excessively. Body Functions My dog has bad breath.My dog has difficulty chewing.My dog's appetite has increased/decreased.My dog is drinking more water than usual.My dog is urinating more frequently than usual.My dog's house-training habits have changed and he/she sometimes has accidents.My dog's bowel habits have changed (increased frequency, diarrhea, constipation, straining).My dog vomits more than occasionally.My dog seems to have trouble seeing or hearing.My dog has been scooting or attempting to lick his/her rear end. Heart / Lungs My dog has been coughing, or seems winded after walking or playing.My dog seems to be panting more. Activity / Orthopedics I have noticed a change in my dog's behavior or activity level.My dog lags behind on walks.My dog has difficulty climbing stairs and jumping.My dog limps, especially after exercise.My dog has lameness (front leg, rear leg, intermittent, persistent) How much and how often does your dog get exercise? Skin and Coat My dog scratches, licks or chews excessively.My dog has changes in haircoat, skin, or new lumps or bumps.My dog's skin has an odor.My dog has bald spots. What foods and treats are you currently feeding your dog? How often? And how much?
Please list current medications/supplements: Do you have any specific questions or concerns about your dog? Pet Name Owner Name Owner Email Date
Please check all that apply to your cat:
Behavior / Neurologic My cat is just not acting like himself/herself.My cat interacts less with the family.My cat seems confused or disoriented.My cat has been meowing or whimpering for no apparent reason.My cat's sleeping patterns have changed.My cat has had tremors or episodes of shaking.My cat has displayed circling, head tilts or repetitive movements. Body Functions My cat has bad breath.My cat has difficulty chewing.My cat's appetite has increased/decreased.My cat has gained / lost weight.My cat is drinking more water than usual.My cat is urinating more frequently than usual.My cat's litter-box habits have changed and he/she sometimes has accidents.My cat's bowel habits have changed (increased frequency, diarrhea, constipation, straining).My cat vomits more than occasionally.My cat seems to have trouble seeing or hearing.My cat has blood in her/his urine and/or stool.My cat has had bouts of weakness or suddenly collapsed. Heart / Lungs My cat has been coughing or sneezing or wheezing.My cat seems to be panting more or having open mouth breathing.My cat tires more rapidly or seems short of breath. Activity/Orthopedics I have noticed a change in my cat's behavior or activity level.My cat has difficulty jumping to furniture/bed.My cat seems limp or seems stiff and has difficulty rising from a resting position.My cat show signs of pain (hiding, unusually quiet, or vocalizing).My cat goes outside. What type of housing do you live in? Skin and Coat My cat scratches, licks or chews excessivelyMy cat has changes in haircoat, skin, or new lumps or bumps.My cat's skin has an odor and/or I have noticed changes in grooming habits.My cat has bald spots. What foods and treats are you currently feeding your cat? How often? And how much?
Please list current medications/supplements:
Do you have any specific questions or concerns about your cat?
Pet Name
Owner Name
Owner Email
Date
Name*
Phone
Email
Message
Species
Sex MaleFemale
I am the owner of the animal identified above and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s)
Admit For
Instructions I understand that during the performance of the previously indicated procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the procedure(s) or operation(s) or different procedure(s) or operation(s) then those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also authorize anesthetics and other medications, and understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed.
Pre-anesthetic blood work is recommended by the doctors in order to evaluate the internal health of your pet before his or her anesthetic procedure. JUVENILE (Under 2 years)ADULT (2-6 years)SENIOR (over 6 years)
Pain medication will be administered to all surgical patients while in the hospital. If needed, additional pain medication will be sent home at the discretion of the doctor.
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT.
Signature of owner/agent: (Entering and submitting name in this form and will constitute signature)
Phone Number (where you can be reached the day of surgery)
Would you like your pet to get a microchip? YesNo
Medications
Owner Name*
Street Address
City
State
Zip
Home Phone
Mobile Phone
Pet's Name
Breed
Age
Color
Medications to be given while boarding. (Please list all, as well as times to be administered)*
* THERE IS A CHARGE FOR MEDICATIONS TO BE GIVEN WHILE YOUR ANIMAL IS BOARDING
Please list all services to be performed while your pet is boarding:
NOTE: All animals entering the hospital MUST be up to date on vaccinations and free of external parasites. (fleas, ticks, etc.), or they will be treated upon entry at the owner’s expense.
Boarding can be stressful for some pets. Stress-related colitis can result from a change in environment, food, water as well as from noise from other pets. Should this occur, Montgomery Animal Hospital will conduct a stool sample analysis and prescribe a medication and/or special food while boarding.
If tranquilizer is necessary for treatment or handling, I give my permission for Montgomery Animal Hospital to administer such medication. I understand that I will be responsible for the charge.
Any pet requiring a bath, due to soiling prior to pick up will be bathed at the owner's expense.
I also authorize Montgomery Animal Hospital to do whatever is necessary should an emergency situation arise. Payment is required when animal(s) is/are released.
SIGNED: (Entering and submitting name in this form and will constitute signature. A signature will be required at check in.)
