PhoneThis field is for validation purposes and should be left unchanged.At Westwood Veterinary Hospital, we offer patient forms online so you can complete them in the convenience of your own home or office.Your Pets Name:*Your Name*Best phone number to reach you at today*Primary concern(s): Please mark all that apply to your pet's current condition. Appetite Change Behavior Problems Blood in Stool Breathing Problems Coughing Diarrhea Ear Problems Eye Problems Gagging Hair Loss Lameness/Limping Increased Thirst Itchy Increased Urination Ingested Foreign Substance Loss of Balance Sneezing Shaking Head Swelling Vomiting Weakness Weight Change (Gain/Loss) Wound(s) Other: If other, please explainPainful? If yes, where?When did you first notice your pet's problem?What medications/supplements does your pet currently take?When did your pet eat last and what is his/her usual diet?Is your pet taking monthly heartworm preventive?Is your pet up-to-date on vaccinations?Please list any vaccinations not administered at Westwood Veterinary Hospital and the dates they were given.I authorize Westwood Veterinary Hospital to perform the following before notifying me: Blood Work Profile: Checks hydration status, anemia, infection, clotting ability, and overall status of immune system. Also checks the kidneys, liver, and pancreas and gives blood sugar levels. Heartworm test: Canine- Checks for heartworms and three tick diseases: Ehrlichiosis, Lymes disease, and Anaplasmosis. Heartworm test: -Feline- Checks for heartworms, Feline Immunodeficiency Virus, and Feline Leukemia Intestinal Parasite Exam: Fecal exam checking for parasites like Hookworms, Whipworms, Tapeworms, Roundworms, Flukes, Coccidia, and their eggs/larvae. Fluid Therapy: Sterile fluids given under the skin or intravenously to help with dehydration or to flush toxins. Radiographs (X-rays)I authorize a maximum expenditure of (fill in a dollar amount below) before the veterinarian/staff consults with me.Promissory Note I understand and agree that I am financially responsible for the payment of all services received and will be charged the interest of 1.5% of any outstanding balance over 30 days. If legal action is required to collect any fees due, I will be required to pay actual court cost and attorney fees.Signature*Date* MM slash DD slash YYYY
