Drop-off Questionnaire – Animal Medical Group

Today's Date

Name

First Last

Preferred Phone #

Alternative Phone #

Who do we contact to get permission to make medical or financial decisions?

Pet's Name

Breed

Chip Number

Sex

Colour

Reason for Visit (check all that apply)

Please specify if you selected 'Illness'

Are there any concerns for: (check all that apply)

When did your pet last eat?

Has your pet ever had an adverse reaction to any medications?

If yes, please describe

Has your pet ever had an adverse reaction to any vaccines, sedation, or any procedure?

If yes, please describe

Is your pet taking any medication(s)

If yes, please list medication(s)

Do you need a refill of these medication(s)

If yes, please list medication(s) in need of refill

Please call me if treatment fee will be over:

*if left blank, we will call if the fee is over $100

Additional Services (Please indicate if you would like your pet to receive any of the following services)