Owner's Name *

First

Last

Email *

Pet's Name *

Has your address changed since your last visit? *

Yes
No

Please enter your new address. *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

What species is the pet? *

Dog
Cat
Exotic

Is your pet being seen by the Veterinarian during your visit? *

Yes
No, Grooming and/or Boarding Only

What is your Pet being seen by the Veterinarian for? *

Preventive Care Update
Surgery
Illness
Recheck Exam

What type of illness is your pet having? *

Does your pet have any history of aggression toward other people or animals? *

Yes
No

To the best of your knowledge has your pet been diagnosed with any previous medical conditions? *

Yes
No

List Previously Diagnosed Conditions:

Is your pet current on flea prevention? *

Yes
No

Type of Flea Prevention:

Is your pet current on heartworm prevention? *

Yes
No

Type of Heartworm Prevention:

Is your pet housed? *

Indoors
Outdoors
Both

Has your pet been given any medications in the last 72 hours? *

Yes
No

List Type and Dosage:

Is your pet receiving any supplements or vitamins? *

Yes
No

List Type and how often you are giving it.

What Breed/Species is your exotic pet?

Where was the pet acquired?

How long have you owned the pet?

Has the pet been bred?

Yes
No

If applicable, when was the last molt or shed?

What other pets are in the household?

What is your pet's main diet?

How often are you feeding your pet?

How much are you feeding?

What type of treats are you giving?

Is the Pet eating and drinking normally?

Yes
No

How does the pet receive water?

What type of enclosure is the pet housed in? (Type, Size)

What type of substrate or bedding is used in the enclosure?

Where in the household is your enclosure/cage located?

Do you have any of the following in the enclosure or cage?

How often is the cage/enclosure cleaned?

What disinfectants or cleaners are used?

When did the symptoms begin?

Is the pet straining to urinate?

Yes
No

Does the pet have a history of urinary tract disease?

Yes
No

What is the consistency of the vomit - if any?

Please specify.

What is the consistency of the diarrhea - if any?

Please specify.

How often is your pet having diarrhea or vomiting?

Please specify.

Has there been a recent diet change?

Yes
No

Is the pet straining to defecate?

Yes
No

Does the pet get table food?

Yes
No

Is the pet left indoors or outdoors unsupervised?

Yes
No

Does the pet have any history of getting into the garbage?

Yes
No

Does the pet have any history of chewing on objects such as toys or strings?

Yes
No

Do any other pets or family members have the same clinical signs?

Yes
No

Does the pet have fleas or any history of fleas?

Yes
No

Have there been any changes in the environment such as a recent move, new food, or a new pet?

Yes
No

What type of changes occurred?

New Food
New Pet
Just Moved
Other

Please specify.

Please Explain the above listed changes.

Regarding the current skin issue - choose one:

This is the first time it has happened.
It seems to happen sporadically throughout the year.
It happens a few times during the year.

Regarding the current skin issue - choose one:

It seems to be associated with certain seasons.
It is not associated with certain seasons.
This is the first time it has happened.

If this is an ongoing issue, what tests have been run to rule out the causes for skin disease?

No testing has been run on my pet.
An allergy test has been run on my pet.
Other

Please specify.

Please list any treatments that have been given by you or a veterinarian.

If you listed treatments above, were they effective?

Yes
No
Other

Please specify.

Regarding the reason your pet is being rechecked, choose one of the following:

The condition has improved
The condition has slightly improved
The condition is the same
The condition is worse

Regarding the pet's illness - is there any likely inciting cause that comes to mind?

Yes
No

Please list the cause:

When do the symptoms seem to be most persistent? *

Is there anything else you would like to report to the veterinarian or would you like to request additional services during your pet's visit? *

Yes
No

Please describe in detail any additional problems you would like to report to the Veterinarian or any additional services requested during your pet's visit.

Do you have any additional instructions or requests for the grooming/boarding staff? *

Yes
No

Please describe in detail the instructions or requests for the grooming/boarding staff.

I hereby authorize the following: *

I hereby authorize the following: *

I hereby authorize the following:

I am the owner of the above Pet, or am acting as an agent for the owner, and accept full financial responsibility for any charges incurred during the pet's visit. I hereby authorize the veterinarian to examine, prescribe for, or treat the above-listed pets. I am aware that other personnel may be required in order to assist the veterinarian. Emergency cases shall always receive top priority, which is why occasional appointment delay is possible. We reserve the right to refuse to accept a pet at check-in for any reason, including without limitation due to illness or behavior.

For your protection, and that of others, we do not allow clients to assist in the restraint of pets, any owner that attempts to restrain or handle their pet while on the premises will be doing so at their own risk. I understand that my pet’s photos may be used for educational or media purposes. All dogs must be on a leash and properly controlled while on the premises. All cats and exotic pets must be presented in an appropriate carrier or on a leash. If you feel your pet may have been exposed to a potentially contagious disease please notify a CVCC staff member prior to the appointment.

We agree to provide the specific services ("Services") to your Pet for each visit as indicated on the estimate. We will exercise reasonable judgment in all circumstances as we provide the services. You agree to pay us for the Services we provide to your Pet during each visit at the rates set forth at the start of such visit (collectively the "Charges"). Prices are subject to change without notice and seasonal rates for boarding and grooming may apply. In the event you do not pay your bill in full at time of check-out, you agree that a fee of 1.5% per month (16% per annum,) will be charged. All collection and attorney fees necessary to collect this debt will be the responsibility of the owner or authorized agent. A returned check fee of $25 will be charged to your account each time we attempt to deposit the check and it is returned as insufficient funds.

Additional charges may be incurred when a pet is very difficult, exhibits risky behavior (biting, snapping, and intolerance to services in general), or has "soiling" behavior. These behaviors increase the amount of time that it takes to provide services for your pet. You acknowledge that we may contact appropriate authorities in the event your pet bites another pet or any person.

While your Pet is in our care, he or she may come into contact with other Pets. Every effort will be made to ensure the safety of our guests by enforcing strict restrictions. You acknowledge and agree that in the unlikely event your Pet is injured by another Pet, you hereby release CVCC from any liability for such injury. If your Pet injures another Pet, you will be solely responsible for any injury to the other Pet(s) as well as your own Pet.

You acknowledge and agree that in the unlikely event your Pet becomes ill or injured, or if your Pet passes away while on the premises, we will attempt to notify you via the telephone numbers you provided. If we cannot reach you, we at our sole discretion, may engage the services of our veterinarian or the area emergency veterinarian (which could be an outside facility) and/or administer medicine or give other necessary attention to your Pet, and you hereby authorize us to provide any such service at your additional expense. You also waive the right to refuse medical treatment to make the pet comfortable or stabilize the pet while under our care and any such service will be provided at your additional expense. If at any time your pet is found to have fleas or ticks while on the premises, we will provide the appropriate flea or tick removal treatment, and you hereby authorize us to provide such service at your additional expense.

Pets under the care of the veterinarian must be discharged by close of business for the day, otherwise the pet will be boarded at the nightly rate until the next business day.

For Boarding and Grooming Services: You represent that to the best of your knowledge, your pet has not been exposed to Rabies, Distemper, Giardia, Bordetella, Intestinal Parasites, or parvovirus within 30 days prior to beginning their stay with us. You acknowledge that the Pet is healthy and we have confirmation from a licensed veterinarian that the Pet has received all vaccinations required, has been examined by a Veterinarian in the last 6 months, and receives monthly flea and heartworm prevention. Boarding check-out time is by 11:00 am on the departure date or a full-day charge will be added to your invoice and the full-day charge will begin on the day you leave your pet.

We will not be responsible for any accidental death of the pet(s) due to the nature of any pre-existing health condition. We also will not be held responsible for minor nicks resulting from the grooming of matted, neglected coats or for irritation caused by removing coat from pets possessing mild to severe skin allergy, nor will we be held responsible for stressful effects that grooming or boarding may have upon a pet. We, as ethical groomers, reserve the right to refuse to demat a pet UNLESS we deem that the pet can tolerate the amount of dematting and that it could be done humanely.

All Pets are required to be vaccinated; however, it is still possible for a Pet to become ill, even if vaccinated. You agree that we are not liable for any illness suffered by your Pet during or after its stay.

Do not bring items with your Pet that are valuable or irreplaceable, We are not responsible for loss or damage to any personal item or toy left with your Pet.

If the pet is not called for at the time of the scheduled pickup date, we have the right to contact appropriate authorities as we see fit (in most cases local animal control officers) within ten (10) days after this date. The owner will receive one (1) notification by registered mail during this period no further notice will be given prior to a decision being made.

By signing you are indicating that you are the responsible party as an adult over the age of 18. You agree that you have full and complete authority to make all decisions, including those related to the expenditure of funds, for or on behalf of you and your pet and that you have had the opportunity to discuss it with us your satisfaction, and you agree to its terms.

Signature *

Date *

Patient History

Patient History Form

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