OwnerOwners D.O.B MM slash DD slash YYYY Spouse/ PartnerAddress Street Address City State / Province / Region ZIP / Postal Code Email [Receive notifications through Petdesk]Home PhoneCell PhoneWork PhoneAlternate Contact (Relationship to youDriver's License number/ StateDriver's License Expiration Date MM slash DD slash YYYY (California State law mandates that license info is provided in order to verify the owner is 18 years or older in order to prescribe controlled medications.)Name of PetSpecies( Dog/ Cat)BreedColorBirthdayGenderSpayed/Neutered?Vaccine HistoryCurrent MedicationCurrent health or behavioral issuesMicrochip NumberName of PetSpecies( Dog/ Cat)BreedColorBirthdayGenderSpayed/Neutered?Vaccine HistoryCurrent MedicationCurrent health or behavioral issuesMicrochip NumberI hereby authorize the veterinarian to examine, prescribe for, treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.SignatureDate MM slash DD slash YYYY AVERAGE EXAM TIME:1 HOUR (SUBJECT TO CHANGE WITH TREATMENT, MEDICATIONS, LABS) ‘** Exam held via phone ** Nordahl Pet Clinic Pre exam notes Date MM slash DD slash YYYY Client NameContact NumberEmail Pet's NmaeAgeCar make and colorListSpeciesBreedColorGenderSpayed/Neutered Vaccine(VX) up to date? Yes No History of VX reaction Yes No Allergens Yes No Present complaints/Comments/Reason for exam:Has your pet been vomiting recently? Yes No If yes, when it started?How long it lastFrequency roughlyHas your pet had diarrhea recently? Yes No If yes, when it started?How long it lastFrequency roughlyHas your pet been coughing recently? Yes No If yes, when it started?How long it lastFrequency roughlyHas your pet been sneezing recently? Yes No If yes, when it started?How long it lastFrequency roughlyHow is your pet's appetite? Good Less None If less or none : when it started?How long it lastHow's your pet's energy now? Good Less lethargic What kind of medication is your pet currently on?Weight*Done by Official Only*
