Comprehensive Exam Drop-Off Form

Please fill out the online form below before you drop off your cat!

If you would prefer to download the form and fill it out at home, please click here.

Owner's Name *

First

Last

Email *

Cat's Name *

Best Person to Contact *

First

Last

Relationship to cat *

Phone *

Alternate Contact *

First

Last

Relationship to cat *

Phone *

May the alternate contact person make decisions regarding your cat on your behalf?

What is the main concern for today’s visit? *

How long/When did you first notice this? *

When was the last time your cat ate/drank? Any change in your cat’s litter box habits (urination/defecation)? *

Please list any medications your cat is on including flea/heartworm prevention and any over the counter supplements: *

In the event that we cannot reach you, would you like to set a dollar amount so that we can proceed with the doctor’s diagnostic/therapeutic recommendations? The comprehensive exam is currently $55.00. *

Yes I would like to set a maximum amount of $_________ in the event that I cannot be reached in order for my cat to be cared for in a more timely manner.
No I do not give my permission to go beyond $55 without discussing further recommendations. I understand that this may delay my cat’s care.

Dollar amount *

Please check all of the following that pertain to your cat and then elaborate at the bottom:

Vomiting/Hairballs
Not Eating
Difficulty breathing/Open mouth breathing
Coughing
Constipation
Increased Drinking
Increased Appetite
Larger urine clumps in litterbox
Itchy Skin
Hair Loss
Sneezing or Nasal Discharge
Blood in stool
Watery or Soft Stool
Blood in Urine
Limping
Change in overall behavior

Please elaborate on any of the items you checked above:

Medical Illness Policy

If your cat(s) becomes acutely critical, we will call the number(s) listed above regarding your cat’s symptoms, treatment options and estimate of additional costs. If no one can be reached, your cat will be treated as deemed best by the doctor and you will assume full responsibility for the expense of the treatment involved.

If the need arises, do we have permission to give your cat a mild sedative?

Yes-please proceed as deemed necessary. I will sign the consent form below.
No- I would want to talk with the veterinarian first about this decision. I will place an “X” on the sedation consent form below and will discuss more with my cat’s veterinarian.

Sedation Consent

With advancements in feline anesthesia, short term sedation/injectable anesthesia has minimal risk in most cats. The procedures and the agents used vary considerably depending on several variables including the age and medical history of your cat, and on the length and type of procedure being performed. However, no procedure is without risk. If your cat has an underlying condition that is not detectable on physical exam or blood work, there could be unforeseen complications and in a rare but worst scenario, death can be the result.

By initialing, I understand the risks of sedation and agree to move forward if necessary for the comfort of my cat and safety of my cat’s caretakers. *

Date *