We truly appreciate your time in giving us the following information as it allows us to be sure that your pet's testing and treatment recommendations are both thorough and personalized to fit your pet and family’s needs. Thank you! Name of owner to contact during the day of your pet’s visit: (Required)
Name of secondary emergency medical contact during the day of your pet’s visit: (Required)
Symptoms & Medical Concerns
Please select each symptom your pet is experiencing (even if only occasional). The more you can tell us the better!
Please select all of the following symptoms (even if they are slight) that your pet is experiencing. (Required) How frequently are they rubbing/scratching/shaking their ears? (Required) Describe any discharge from the eye (Required) If your pet has nasal discharge or something comes out when they sneeze, please describe the discharge. (Required) How frequently is your pet sneezing when you are with them? (Required) Describe what you have noticed going on with your pet's mouth/breath. (Required) How has this changed the way your pet chews or what they are willing to eat? (Required) How often does your pet cough in a 24 hour period? (Required) If your pet is not coughing, but has changes in breathing, please describe the changes you are noticing. (Required)
Please bring a fresh urine sample to the visit.
Please bring a stool sample to the visit.
Please describe where these lumps/lesions/rashes are (we may also shave small spots on them for examination): (Required) When you are with your pet, how often are they licking or scratching? (Required) Have you noticed any of the following additional symptoms? (Required) Please tell us what you are noticing (Required) Has your pet had any x-rays, blood or urine testing done at a facility other than Healing Paws in the last 6 months? (Required) Let's Work Together to Make Treatment Easier
We recommend whole pet care that may include medical, nutritional, surgical, supplemental, or integrative therapy. Help us help your pet by answering the following.
To help us make medicating your pet easier, please select all that applies: (Required) What did you try to get them to take the pills? Tell us what this experience was like for both you and your pet? (Required) What did you try to get them to take the liquid? If you recall, what flavor was the liquid? How stressful was this experience for both you and your pet? (Required) Does your pet eat dry food/kibble? (Required) Does your pet eat canned or moist food? (Required) Does your pet eat treats, bones, chews or people food? (Required) Does your pet currently take any prescribed medications (other than parasite preventatives)? (Required) Even if you get the medication from us, it is very important to give as thorough detail as possible to avoid drug interactions. Please list the medications including how much and what times of day you give them. (Required) Does your pet receive any over the counter medications, supplements, herbs, or vitamins? (Required) Please list any of these products that your pet receives - including how much and what times of day you give them. It is very important to give us as thorough detail as possible to avoid drug interactions (Required) Would you like any medication, supplements, dental care products, foods, or parasite preventatives refilled today? (Required) Pease list all products and how many months supply you would like of each (Required) Important Authorizations Authorization to Perform Examination/Diagnostics/Treatment: I hereby authorize the Healing Paws Veterinary Care, Inc. staff and doctor to perform an examination. I understand that the condition my pet has may include them having pain or anxiety and also authorize the Healing Paws Veterinary Care, Inc. staff and doctor to provide short-term pain or anxiety relief to my pet during their stay. At the end of the examination, if the doctor feels that further diagnostic testing is necessary, the tests may be performed during my pet's visit. With the results of those tests, I understand that the doctor will personalize a treatment recommendation for my pet and then will review those recommendations with myself or my representative. I understand that receiving diagnostic testing and treatments allows my pet to feel more comfortable as soon as possible and allows the doctor to evaluate their results and treatments so that I can receive the most accurate treatment recommendation plan (Required) CPR/DNR Consent
In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being at Healing Paws Veterinary Care today, we need to know, in advance, what your wishes are for your pet. If your pet does experience cardiac or respiratory arrest, we will absolutely inform you. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.
Cardiopulmonary Resuscitation (CPR):
All resuscitative efforts are to be attempted to restore normal heart function and to breathe as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursue medical care. I understand that this is a cost in ADDITION to any other services provided, and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a specialty facility following resuscitation. It will be necessary for me to transport my pet to the specialty facility, and I will be responsible for the charges for my pet's care at that facility.
Do Not Attempt Resuscitation (DNR):
No cardiopulmonary resuscitation (CPR) efforts will be performed in an effort to save my pet if they have cardiac or respiratory arrest; only the administration of medication to help ease my pet's passing may be used.
Please select the option you'd like the doctors to proceed with. (Required)
Information About Veterinary Medical Care
I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses or effectiveness of preventative care products and procedures. I have been informed that there are certain risks and complications associated with disease, sedation, anesthesia, and/or any operation/procedure and that while the team at Healing Paws Veterinary Care, Inc has my pet's best interest in mind at all times, sometimes complications occur. I further understand that during the course of the examination, diagnostics, procedures, or treatments, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before treatment or diagnostics are initiated. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care. I accept that my financial obligations remain regardless of the outcome of treatment.
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute consent for examination, diagnostic testing, procedures, and treatment of said animal. I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination and treatment. I understand that I am financially responsible for any services, products, or treatments provided to my pet and that I can request a treatment plan and cost estimate for my pet at the time of my visit. (Required) My signature below certifies that I am over eighteen years of age. (Required)
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