HEALTHY pet Drop Off Questionnaire

Name of owner: ___________________________ Today’s date: ___/___/___

Name of patient:___________________________

What procedure(s) is(are) to be performed today?____________________________________

___________________________________________________________________________

How has your cat been (eating, drinking, activity)?____________________________________

Have you noticed any new problems, issues, or behaviors since the last visit? ______________ ____________________________________________________________________________

Does your cat go outside EVER (even if supervised)?_________________________________

Does your kitty have any significant medical history? If so, what/when?___________________

____________________________________________________________________________

Is your cat currently taking any medications (including heartworm or flea prevention)? When was

last dose given?________________________________________________________________

Do you need refills of any medications or supplies?____________________________________

Has your cat eaten today? When?_________________________________________________

What does your cat eat? (include brands and types of all dry, canned, and treats: e.g. Iams Active Maturity)___________

_______________________________________________________________________________________________________

What type of medication is easiest for you to give your cat if needed? PILLS LIQUID

Do we have permission to run diagnostic lab work (bloodwork, urine tests, fecal) to determine the state of the internal organs (especially important in senior cats)? (Please circle one) NO YES

Do we have permission to sedate and/or anesthetize your pet to examine, run diagnostics, and/or treat the problem(s), understanding that there may be cardiopulmonary risks associated with sedation? (We will NOT sedate unless the patient presents danger to itself or our employees.)

NO YES

Please leave phone number(s) where you and/or an “agent” can be reached today if

we need to talk with you.__________________________________________________________

Due to the nature of “drop-offs,” we may communicate through our health care team members or written information. You are

welcome to call during the day for updates and information.

---If we find any evidence of fleas on your cat, flea control may be applied to prevent spread in the hospital.--

Please sign below to authorize the above procedures. Thank you!

____________________________________ ________________

Signature Date