ELC Veterinary Clinic - Additional Pet Form

Pet Health History

Owner's First Name

Owner's Last Name

Name Of Pet

 Dog Cat Other

Breed:

Color:

Birthdate:

Date / time of appointment:

 Male Female
 Neutered Spayed Not Neutered Or Spayed

Vaccination History (Date and type of last vaccinations):

Please check any symptoms that you have noticed for your pet.

 Behavioral Problems Bleeding Gums Breathing Problems Coughing Diarrhea Eye Bulging or Bloodshot Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Thirst and/or Urination Increased Vomiting Weakness No Symptoms

Pet's current medications

Describe your pet's diet:

Authorization

I hereby authorize the veterinarian to examine, prescribe for and/or treat the pet described above. I assume full responsibility for all change included and the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

Signature of Owner or Responsible Agent (print your name):

Date:

I agree that ELC Veterinary Clinic may use photographs of my pet with or without the pet's name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

 Yes No

Professional Fees Are Due At The Time Services Are Rendered

Please ask a member of our Healthcare Team for a written estimate of potential costs.

There are no staff on duty after hours.