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Date*

Date Format: MM slash DD slash YYYY

Primary Owner(s) Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Today's Phone Number:*

This is the phone number we will use to call you once the veterinarian has examined your pet so please make sure you have your phone on you and please stay close to the clinic.

Emergency Contact Name

First Last

Emergency Contact Phone Number

Pet's Information*

Pet Name: Pet's Age or Date of Birth Dog or Cat: Breed: Colour:

Upload a picture to file if applicable

jpg, gif, png, pdf

Presenting Complaint: What is your pet here for today?*

Duration of time (When did the problem start, has it changed, better, worse, same?):*

Diet (EXACT Brand, amount, frequency):*

Any Vomiting/Diarrhea/Coughing/Sneezing:*

Is the pet currently on any MEDICATIONS INCLUDING SUPPLEMENTS (Name, amount, frequency, last given):*

Any changes in appetite or drinking/urinations (drinking or peeing more often?):*

Any other pets in house? No Are they affected?*

Has your pet been fasted? If not, when was last meal?

Indoors/outdoors?*

Are your pet's vaccines up to date?*

As the owner or agent of the owner of the above animal, I hereby give my consent to Yonge-Davenport Pet Hospital to perform the following procedures:*

I, the owner of the pet mentioned above consent to (SELECT ONE BELOW):*

A. The veterinarian being authorized to administer or dispense all items listed above as well as any other treatments or diagnostics the vet deems necessary without further authorization on my part.
B. The veterinarian MUST CALL ME BEFORE performing or administering any treatments or diagnostics BEYOND A PHYSICAL EXAM.

Additional Services: Please note any additional services that you would like us to perform while your pet is at the clinic. Additional fees may apply:

Consent*

I agree to the COVID-19 examination policy.

I understand that during the performance of these procedures, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect Yonge-Davenport Pet Hospital to use reasonable care and judgement in performing the procedure(s). The nature of the procedure and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding my pet.

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