Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

describe Name how

Species *

Dog
Cat
Other

If other, please specify: *

Breed *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

What will we be seeing your pet for today? *

Primary Complaints *

If other, please specify: *

If your pet has any unusual lumps, bumps, wounds, or skin irritation that you would like the veterinarian to address today, please note the locations here:

Was your pet fed today? *

Yes
No

Time of meal? *

Is your pet current on vaccines? *

Yes
No

Any previous injury or illness?

Please list any medications your pet is currently on.

Is your pet on heartworm/flea and tick medication? *

Yes
No

What type of heartworm and flea/tick medication is your pet using? *

Last given: *

What type of diet do you feed your pet? How much and how often? *

Please describe any other issues you would like addressed today.

If the veterinarian recommends, we may need to perform lab work depending on symptoms. *

Yes, please run the tests.
No, not at this time.
Please call me first.

If the veterinarian recommends, we may need to perform diagnostic testing, such as x-rays. *

Yes, please run the tests.
No, not at this time.
Please call me first.

I hereby give my consent to the Cedar Lake Animal Hospital to perform an exam and treatment(s). *

I have read and understand.

Signature *

Clear Signature

Date *

Drop-Off Form

Drop-Off Form

Ready to Visit?

Location

Contact Information

Hours

Have a Question?