Concierge Appointment Form

Because of your absence during your pet’s medical exam, please complete the following as thoroughly as possible so the doctor can accurately diagnose your pet’s condition.

Pet Name*

Reason(s) for medical exam*

How long has the current medical problem occurred?

Is your pet currently on any medications for this problem? (please list)

Have you noticed any of the following symptoms? (Please mark yes to all that apply & describe in detail below.)

Diarrhea
Vomiting
Decreased/Increased Thirst
Pain
Nasal Discharge
Odor
Flea/Tick
Lethargy
Decreased Appetite
Limping
Coughing
Urinating/Defecating Problems
Ear Discharge/Odor
Heartworm
Swelling
Discharge
Discoloration
Sneezing
Skin Problems
Behavior Problems
Diet

Would you like the following performed if due?*

Fecal Test

Heartworm Test

Vaccinations

I, the owner of the pet listed above, am authorizing consent for treatment, x-rays, or lab work if the doctor considers this necessary to diagnose the condition(s) above:*

I agree

Would you like to be informed of an estimate before diagnostics or treatment is performed

Yes