Drop off Questionnaire for sick or injured pets

Name of owner: ___________________________ Today’s date: ___/___/___

Name of patient:___________________________

When did you first notice a problem?___________________________________

What signs/symptoms/wounds did you first notice?________________________

________________________________________________________________

Have the signs gotten worse, better, or stayed the same? Have you noticed any new

problems or behaviors since it began?______________________________

________________________________________________________________

How has your cat been otherwise (eating, drinking, activity)?________________

________________________________________________________________

Does your cat go outside EVER (even if supervised)?______________________

Does your kitty have any significant medical history?_______________________

________________________________________________________________

Is your cat currently taking any medications?_____________________________

________________________________________________________________

Has your cat eaten today? When?_____________________________________

Do we have permission to sedate and/or anesthetize to examine, run diagnostics,

and/or treat the problem(s)? (Please circle one) NO YES

Do we have permission to run diagnostic blood work if necessary to help figure out the

problem and determine the state of the internal organs? NO YES

Do we have permission to take radiographs (x-rays) if necessary? NO YES

Please leave phone number(s) where you and/or an “agent” can be reached today if we

need to talk with you.______________________________________

---If we find any evidence of fleas on your cat, flea control will be applied to prevent spread in the hospital.---

Please sign to authorize the above procedures. Thank you!

____________________________________ ________________

Signature Date