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Sick Pet Info Form

Are you planning on dropping off your sick pet to be seen? If so, you can save some time by filling this out in advance (provided he/she is not critically ill).

Owner's Name*

First

Last
Phone Number*
Email
Have you been here before?*
- Yes, i’m an established client
- No, i’m a new client
Pet's Name*
Species and Gender*
- Dog
- Cat
- Male
- Female
Recent History
Has your pet visited another vet for an emergency or other services? IF YES, please list details:
List any chronic medical problems here.
Explain any prior injuries here.
List any known allergies your pet has.
Is your pet currently on any OTC medications? If yes, please list here.
When was the last dose of heartworm preventative administered?*
- Never
- This Month
- Last Month
- Over 2 Months Ago
Symptoms
Check all that apply:
- Acts Painful
- Coughing / wheezing / sneezing
- Gagging / choking
- Tremors / seizures
- Increased / decreased appetite
- Increased / decreased weight change
- Increased / decreased thirst
- Increased / difficult urination
- Decreased eyesight
- Eye or eyelid drainage / redness
- Decreased hearing
- Ear odor / drainage / pain
- Head shaking
- Scratching at ears
- Excessive panting
- Bad breath / mouth soreness
- Loss of house training
- Abdominal pain / swelling
- Vomiting / abnormal stools / diarrhea
- Scooting / chewing at rectum
- Difficult defecation
- Itching / scratching
- Poor coat / hair loss
- Skin lumps / bumps
- Hair loss / redness of skin
- Unusual body odor
- Difficulty climbing / rising
- Difficulty / reluctance to jump up
- Lagging behind on walks
- Stiffness / lameness / weakness
- Toe nail(s) overgrown
- Change in activity level
- Confusion / disorientation
- Less interactive with family
- Decreased responsiveness
- Changes in sleeping pattern
- Bleeding / unusual discharge from any body orifice
- Anxiety / whining / fear of loud noises / separation
- Cats Only: Vertical scratching / spraying / fear of carrier
Other symptoms not listed above:
Details

(Please elaborate on the symptoms you checked)
How long have noticed these symptoms?*
How often do these symptoms occur?*
Are the symptoms improving, staying the same, or worsening?*
For Drop-Off Appointments ONLY:
IF NECESSARY, may we SEDATE, do preliminary bloodwork, submit urinalysis, or take x-rays?
- YES, please proceed with whatever testing and treatment the doctor feels is needed.
- NO, I must be contacted before any testing or treatment is performed (other than what I may have already authorized). **Your pet will NOT receive any (or additional) treatment until we are able to reach you.**
- YES, please proceed with testing and treatment UP TO the dollar amount listed below without contacting me.
Dollar ($) amount limit:
What time do you plan on picking up your pet?
Phone number where we can reach you:
Do you already have an appointment set up with us?
- Yes
- No
If so, when?
Do you have a doctor preference?
CAPTCHA

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What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

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Manchaca Village Veterinary Care

12117 Manchaca Rd,
Austin, TX 78748

Call 512-VET-CARE / 512-838-2273
Text 512-838-2273
Email [email protected]

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Emergencies

During operating hours, call us at 512-VET-CARE (512-838-2273).

After hours, please call the Emergency Hospital at 512-899-0955.

Monday

7:00am - 6:00pm

Tuesday

7:00am - 6:00pm

Wednesday

7:00am - 6:00pm

Thursday

7:00am - 6:00pm

Friday

7:00am - 6:00pm

Saturday

8:00am - 12:00pm

Sunday

Closed

Click for Holiday Hours

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