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Client ID

Call clinic or obtain from a prior invoice.

Patient ID

Call clinic or obtain from a prior invoice.

Client Name

Pet Name

Address

City

State

Zip

Phone

Email

Species

Breed

Sex

Color

We may need to contact you or someone with permission to make medical and financial decisions. Please provide the best contacts or a secondary contact that the number listed above.

Name of staff member who helped you at check in?

What is the reason for your visit? Please describe any specific problems you would like the doctor to address.

Any coughing/sneezing/vomiting/diarrhea?

If so, for how long?

Has your pet been drinking more water or urinating more frequently?

If so, for how long?

Do you take your dog swimming, on hikes, or in the woods?

Does your cat go outside?

Does your pet do the following?

Boarding
Grooming
Dog Parks
None

Would you like your pet's nails trimmed today? ($24)

Do your give your pet a heartworm preventative?

If yes, what brand(s)?

Date last given?

Do your give your pet a flea/tick preventative?

If yes, what brand(s)?

Date last given?

If your pet is due for heartworm or flea prevention, would you like us to refill your prescription?

If yes, how many would you like to refill?

When did your pet last eat? (date & time)

What type of food do you feed your pet?

How much do you feed?

Any increase or decrease in appetite?

List any medication(s) and/or supplements, as well as instructions, that your pet is currently taking.

Has your pet had these medication(s) today?

Which ones?

Do you need any of these medication refilled?

If yes, which ones?

May we sedate your pet if necessary?

The cost of sedation is $65/cat and $91/dog (plus $50 Preanesthetic Exam if needed).

Yes
No
Call you first

May we use your animal's picture on our website and/or in our social media sites?

I herby authorize the veterinarians at Brookstone Animal Hospital to examine, prescribe and treat my pet as set forth above or as they deem necessary. I agree to assume full responsibility for treatment expenses involved and to pay the fees for all services rendered at the time my pet is discharged from the hospital.

I accept.

May we preform CPR on your pet if necessary?

I understand that while my pet is under the care of Brookstone Animal Hospital a rare life-threatening complication, such as respiratory and/or cardiac arrest, may occur. This complication may require cardiopulmonary resuscitation (CPR). If my pet stops breathing or its heart stops beating, I realize even the most successful CPR may not restore him/her to good mental and physical health. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. In spite of the limited likelihood of success from CPR treatment, by checking one of the following choices, I hereby request:

Yes, perform CPR on my pet if doctor deems necessary ($54 service charge)
No, do not attempt to resuscitate my pet

notes

I accept that if hospital staff members are unable to reach me within 20 minutes after the initiation of CPR, and after administering reasonable treatment and there appears to be virtually no hope for medical success, CPR will be withdrawn and my pet will be humanely euthanized. I am providing the hospital with phone numbers at the top of this form at which I can be reached in the event of a decline in my pets condition.

Client Signature

Today's Date