Medical Form – Lake Road Animal Hospital

Medical Concern History Form

Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.

We ask that one to two adults be present at your pet’s exam since our exam rooms are too small to accommodate many people.

The check-in and check-out processes for all visits will occur over the phone, so please provide the information below even if you intend to attend your pet’s appointment. Thank you!

Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Reason for visit: (check all that apply) *

Illness
Injury
Other

What symptoms has your pet been experiencing?

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them?

No change
Worsened
Improved

Has your pet experienced this problem in the past? *

Is your pet on any medications? *

What kind of food do you feed your pet? *

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

Have there been any changes in appetite? *

Increased
Decreased
No change

If there has, for how long? Please elaborate. *

Any increase or decrease in water consumption? *

Increased
Decreased
No change

Any change in bowel movements? *

Yes
No
Unsure

Does your pet spend time outside, even for walks or in the yard? *

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

Was your pet last seen by a veterinarian at Lake Road Animal Hospital? *

Once your pet’s exam is completed, we will discuss the exam findings and recommendations.

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Lake Road Animal Hospital authorization to treat as discussed above. *

I have read and agree

If you are ill or have had close contact with someone who is ill, please consider a fully curbside appointment or wear a mask for the safety of our team. Mask can be provided.

Please call or text our team when you arrive to check in. When the room is ready for your pet we will call or text you to enter the building and escort you to the room. Wearing a mask is recommended. Once the exam has been performed and a plan has been discussed and approved with the veterinarian, we ask that you return to your vehicle while the doctor and nurses complete the services discussed (such as bloodwork, x-rays, or other therapies). Once completed, we will call or send a secure link for payment and bring your pet back to you. This will allow for proper cleaning time between patients to keep all of our patients, clients, and team members as healthy as possible. *

I have read and understand.

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet. *

I have read and understand.

Please type your initials. *

Date *