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 EmailThis field is for validation purposes and should be left unchanged.
