Pet Drop Off Exam Questionnaire

Name: *

First

Last

Email: *

Please Explain Your Pet's Condition For Visiting With NPVC Today. Include All Symptoms That Need To Be Improved By Treatment: *

NOTE: There Is An Exam Fee For Your Pet's Visit.

When Did Your Pet's Symptoms Begin? *

How Have The Symptoms Progressed? *

List Any Treatments Used In The Past That Have Relieved Symptoms: *

What Do You Think Is Causing The Symptoms Your Pet Is Showing? *

What Is Your Expected Outcome Of Treatment? *

What Medications, Supplements, Ointments, And Treatments Have Been Given To Assist The Symptoms You Are Seeing? *

What Medications Does Your Pet Normally Get? *

What Is the Last Thing Your Pet Ate? *

When Did Your Pet Last Eat? *

Have You Seen Any Vomiting? *

When / Where Was The Last Stool Your Pet Passed? *

What Did The Stool Look Like? *

When / Where Was The Last Urine Your Pet Passed? *

What Did The Urine Look Like? *

Have You Seen Any Changes In Drinking? *

Have You Seen Any Straining To Urinate? *

How Often Does Your Pet Urinate Daily? *

What Is Your Pet's Current Level Of Discomfort / Pain?

Selected Value: 0

1 = Little Pain, 10 = Severe Pain

In Case Of Emergency, NPVC Needs Permission To Perform CPR On Your Pet. If You would Prefer For No Resuscitation To Occur (DNR), Please Provide Your Electronic Signature Below:

Additional Services May Be Requested / Recommended. There Will Be Additional Fees For These Services:

Please Check The Diagnostic Testing NPVC Has Permission To Perform While Your Pet Is With Us: *

If Other Please Indicate Below

Other: *

Please Check The Additional Services You Would Like Performed Today: *

Other: *

If Other Please Indicate Below

Is There Any Treatment, Diagnostic Testing, Ingredients, Or Therapy You Are Displeased With Or Will Not Accept If Offered / Suggested Today? *

Will You Consider Referral For Further Treatment, Care, Chemo, Or Imagery? *

What Amount Of Time And Money Have You Budgeted For Care For Your Pet's Symptoms? *

What Would You Prefer To Do If Complete resolution Cannot Be Achieved For Your Pet's Symptoms? *

Referral
Second Opinion
Continued Partial Care
Euthanasia