Owner Information

**Owner First Name** *

**Owner Last Name** *

**Email** *

**Primary Phone** *

**Address** *

City *

State *

Zip Code *

Emergency Contact

**Primary Emergency Contact Name** *

Primary Emergency Contact Phone *

Do you authorize your emergency contact to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

**Pet Name** *

**Birth Date / Age** *

**Species** *

Dog

Cat

Breed *

**Vaccination Status** *

Current

Past Due

Unsure

**Is your pet currently up to date with their heartworm preventive?** *

Yes

No

Unsure

**Gender** *

Male

Female

**Spayed/Neutered?** *

Yes

No

Unsure

**What is your primary concern for your pet?** *

Murmur on routine exam

Murmur pre-anesthesia

Cough

Increased breathing rate/loud breathing

Collapse or seizure

Arrhythmia

Other

Presenting problem, special needs, concerns *

**What is your pet's social history?** *

Adopted - recently

Adopted - 1+ year ago

Solo pet with no other animal interactions

Interaction with other family pets

Limited interaction outside the household

Routine interactions at dog parks/ day care centers

Recent boarding or grooming

**Is your pet having coughing episodes?** *

Yes - at rest (any time)

Yes - during exercise

Yes - at rest (night time)

No

**If your pet is coughing, please check all that apply:**

Cough has gotten progressively worse

Cough has stayed the same

Cough is only occasional

Soft cough

Hacking cough

Prolonged coughing fits

Gag at end of cough

**Does your pet breathe normally?** *

Yes

No

If your pet does not breathe normally, please check all that apply:

Increased breathing rate - always

Increased breathing rate - at rest

Increased breathing rate - activity only

Loud breathing - activity only

Loud breathing - activity and rest

Exercise intolerance - mild

Exercise intolerance - moderate

Exercise intolerance - severe

**Has your pet had any weakness of the limbs?** *

Yes - general

Yes - rear end only

No

**Has your pet had any collapsing episodes?** *

Yes - at rest

Yes - during activity

Yes - stiffened, may vocalize, quick recovery

Yes - legs moving, slow recovery

Yes - other

No

**Has your pet experienced any unusual vomiting?** *

Yes

No

If yes, please explain (frequency, when vomiting started, etc.):

**Has your pet had any diarrhea?** *

Yes

No

If yes, please explain (frequency, when diarrhea started, bloody, etc.):

**What do you feed your pet? (Please list brand, treats, and if your pet receives table scraps)** *

**How is your pet's recent appetite?** *

Good

Fair

Fair and needs enticing to eat

Picky eater

Poor

Not eating currently

**Has your pet's weight changed?** *

Yes - increased weight

Yes - lost weight

No

**What is your pet's drinking habit?** *

Normal

Increased drinking and/or urination

Increased drinking and/or urination attributed to medication

Incontinence noted - urinates without being aware of it

**Has your pet travelled outside of Colorado?** *

Yes

No

If yes, when and where?

**Is your pet on any medications or supplements?** *

Yes

No

If yes, please list:

**Has your pet ever had any surgeries?** *

Yes

No

If yes, when and what for?

**Has your pet been diagnosed with any diseases or conditions?** *

Yes

No

If yes, please explain:

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Choice Veterinary Specialists to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

Please check this box if you do not want photos of your pet to be used by Choice Veterinary Specialists for media, educational, or other purposes.

By submitting this form, I hereby authorize Choice Veterinary Specialists to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Choice Veterinary Specialists.

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