Canine Well Patient Drop Off Form

Open: Mon, Thurs: 7:30AM - 8:00PM
Tues, Wed, Fri: 7:30AM - 6:00PM
Sat: 8:00AM - 2:00PM
Sun: CLOSED

[email protected]
(214) 225-3729
After-Hours Emergency Information

We have arranged for you to leave your pet here, to allow examination of your pet as soon as possible today. Please read through the following questions, and answer any that may apply to your pet today.

Client Name

Address

Telephone

Patient Info

Name

Species

Breed

Sex

Color

Services requested

Please provide a list of any concerns:

What heartworm and flea/tick preventative are you using?

Do you need a refill?

What brand of food do you feed your dog?

Do you provide dental care for your dog?

Yes

If no, are you interested in providing dental care?

Yes

General health questions regarding your pet

Has your pet had any Vomiting?

Yes

Has your pet had any Diarrhea

Yes

Has your pet had any Limping?

Yes

Has your pet had any Soreness?

Yes

Has your pet had any Coughing?

Yes

Has your pet had any Sneezing?

Yes

Has your pet had any Lethargy?

Yes

Has your pet had any Growths?

Yes

Has your pet had an

increase

decrease in water consumption

no change

Has your pet had an

increase

decrease in food consumption

no change

Has your pet had an

increase

decrease in urination

no change

If intact, last heat cycle?

Any chance your pet is pregnant?

Yes

Is your pet on any medications? If yes, please list:

General questions to help us choose the best vaccination protocol for your pet:

Has your pet ever had a vaccination reaction?

Yes

Does your pet go to boarding or grooming?

Yes

Does your pet go to heavily wooded areas, lakes, or farms with cattle?

Yes

Does your pet go hunting?

Yes

Do you have any problems with ticks?

Yes

Does your pet have access to wildlife or cattle?

Yes

I am the owner/agent for described animal, and authorize, and request the above services be performed for my pet. I can be reached at

Agreement *

I agree

Visit our office to get the latest in top-quality veterinary care along with unparalleled service.

Address: 8541 Ferguson Road
Dallas, TX 75228
Phone: (214) 225-3729
Email: [email protected]

East Dallas Veterinary Clinic

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The content provided on this website is intended for educational purposes only. East Dallas Veterinary Clinic does not provide veterinary medical advice via the internet. Please consult your veterinarian for the best recommendations for your pets. ©2023 East Dallas Veterinary Clinic. Resource Articles ©2023 GeniusVets. All Rights Reserved. Veterinary websites by GeniusVets

Canine Well Patient Drop Off Form

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