Sick Pet Form – Manchaca Village Veterinary Care.

Owner's Name*

First Last

Phone Number*

Email

Have you been here before?*

Pet's Name*

Species and Gender*

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?*

Check all that apply:

Other symptoms not listed above:

(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?*

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?

If so, when?

Do you have a doctor preference?