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Dental month 2/1 to 2/28! Get a free bag of dental chews, plus $75 off all dental in Feb!

Pet Drop-off Form

Owners Name(Required)

First Last

Pet’s Name(Required)

Daytime Phone(Required)

Alternative Phone

Pet is here for

Exam & Vaccinations

Sickness-Injury

Sickness-Injury

Please describe sickness/injury(Required)

How long has your pet experienced this condition?(Required)

Has the condition occurred in the past?(Required)

Yes

No

How was it treated?(Required)

Has your pet been receiving any medication?(Required)

Yes

No

If yes, what and how often?(Required)

Do we have permission to perform blood work if necessary?(Required)

Yes

No

Initial here(Required)

Do we have permission to take x-rays and sedate you pet if needed?(Required)

Yes

No

Initial here(Required)

General Information

Your pet’s appetite is normal/excessive/poor/absent?(Required)

What is your pet fed?(Required)

Water consumption is: the same/increased/decreased?(Required)

Energy level is: the same/increased/decreased?(Required)

Has your pet been coughing?(Required)

Yes

No

Sneezing?(Required)

Yes

No

Has your pet been exposed to any other animals?(Required)

Yes

No

What and when?(Required)

Gastrointestinal System

Is your pet vomiting?(Required)

Yes

No

Last vomited?(Required)

Your pet’s bowel movements are: normal/hard/soft/diarrhea/bloody/unsure?(Required)

Last bowel movement(Required)

Frequency(Required)

Voluntary/Involuntary(Required)

Could your pet have eaten something other than its food?(Required)

Yes

No

What?(Required)

Could your pet have been exposed to any toxins i.e. fertilizers, chemicals?(Required)

Yes

No

What?(Required)

Urinary System

Is your pet straining to urinate?(Required)

Yes

No

Is your pet urinating frequently?(Required)

Yes

No

Does your pet have bloody urine?(Required)

Yes

No

Does your pet have bloody urine?(Required)

Yes

No

Odor?(Required)

Yes

No

Blood tinged?(Required)

Yes

No

Last urinated?(Required)

How much?(Required)

Skin

Is your pet itchy?(Required)

Yes

No

Is the skin red?(Required)

Yes

No

Is the skin oozing?(Required)

Yes

No

First noticed problem?(Required)

Is your pet on flea control?(Required)

Yes

No

Is there a lump?(Required)

Yes

No

Is the lump getting larger/smaller/staying the same?(Required)

Where on your pet is the skin problem or lump?(Required)

Muscular and Skeletal System

Is your pet's leg(s) lame(Required)

Yes

No

In which leg(s) is your pet lame?(Required)

First noticed lameness?(Required)

Has the lameness gotten worse/better/stayed the same?(Required)

Has your pet been licking or biting at specific areas?(Required)

Yes

No

Please explain(Required)

Please give a brief history of the event(s) that may have caused this, if known(Required)

Anything else?(Required)

Date(Required)

MM slash DD slash YYYY

Signature of Owner(Required)

CAPTCHA

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1150 E Eldorado Pkwy #400, Little Elm, TX 75068

Phone: (972) 987-4675 vwclittleelm@gmail.com

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