Medical Check-In – Outpatient Owner's Full Name*Email* Pet's NamePhone*Date of Drop Off Date Format: MM slash DD slash YYYY Reason for VisitIf sick, how long?Pet's Current DietMeals Per DayOne (1)Two (2)Three (3)Free Food (food down all the time)Does he/she get table scraps (people food)?YesNoHas he/she eaten today?YesNoHas he/she urinated today?YesNoHas he/she defected today?YesNoPatient Medical HistoryPlease mark all that apply. We may ask additional questions when you drop your baby off with us for clarification.Recent injury, accident or surgery?Please list any medications currently being taken.Any known allergies to medications? If yes, please list.Please check all that apply to today\'s visit. (check all that apply) We may ask you additional questions on drop-off. Vomiting and/or Diarrhea Bowel Abnormalities Drinking More or Less than Usual Coughing, Sneezing or Gagging History of Seizures Weight Loss or Gain Bad Breath Heartworm Preventative Well Pet Exam Urinating More or Less Than Usual Lack of Energy and/or Weakness Limping Scratching and/or Chewing at Skin Any Lumps or Bumps on Pet\'s Body Increase/Decrease in Appetite Behavioral Change(s) Other Please Check the Service(s) you are requesting today.Physical Examination with emphasis on the problem(s) listed above.Annual check-up and boost my pet\'s vaccines against contagious disease.Check my pet for heartworms and/or parasitesOtherAuthorizationNotification Your pet will be administered a Capstar® tablet orally on the morning of admission, so that we can remain a ”flea free” facility. You are authorizing Claws & Paws Veterinary Hospital® and it’s staff to perform the requested procedures based on your responses to the next two choices and submitting this electronic form.I authorize sedation or pain relief for the examination or treatment if necessary.*YesNoCall me firstPlease contact me before proceeding with any diagnostic or treatment.*YesNoCAPTCHANameThis field is for validation purposes and should be left unchanged.