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12117 Manchaca Rd., Austin, TX 78748
512-VET-CARE / 512-838-2273
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Home
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Forms
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Sick Pet Info Form
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?
No
Dr. Ontiveros
Dr. Smith
Dr. Lubitz
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Find Us
Online Pharmacy
PetDesk
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.
Make An Appointment
