Drop Off Examination Online Form

Fill out the following form and submit it online. Saves you on printing costs, saves your time, and helps you to go green!

NOTE: This form is only to be filled out and submitted the day you intend on bringing your pet in.

Date:
Owner Name:
Pet Name:
Phone # to Reach You At While Your Pet Is Here:
What time do you plan on picking up your pet?:
Reason for Visit/Examination Today:
Type of Environment Your Pet Spends the Most Time In:	Indoor   Outdoor
Is Your Pet Vomiting?	Yes   No
Does Your Pet Have Diarrhea?	Yes   No
If so, please describe the color, consistency, and frequency:
Describe Your Pet's Appetite:	Increased Decreased Stayed the Same
Describe Your Pet's Water Consumption:	Increased Decreased Stayed the Same
Describe Your Pet's Urination:	Increased Decreased Stayed the Same
How long has your pet had this problem?:
Has it gotten worse?	Yes   No
Has this problem been treated elsewhere?	Yes   No
If so, may we request your pet's medical records?	Yes   No
Name of Veterinarian/Clinic:
What medications have been given?:
Has your pet eaten today?	Yes   No
If yes, when?:
To diagnose and treat many problems, blood work, X-rays or other tests may be necessary. Do you give consent to perform such blood work, X-rays or other tests that the veterinarian feels are necessary to properly diagnose your pet? ?	Yes   No
Does your pet have skin problems?	Itching Scaling Crusting Redness Hair Loss
If your pet needs a lump or skin lesion checked, please describe in detail where it is located.

2504 Mall Dr. Eau Claire, WI 54701. 715-835-5011. Fax: 715-835-0993. Site Designed and Hosted by Wireless Wisconsin LLC.