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Drop-Off Form - Powell Animal Hospital - Powell, TN

Powell Animal Hospital

205 Star Mountain Way (Formerly500 W Emory Rd)
Powell, TN 37849

(865)938-1884

powellanimalhospital.com

Drop-Off

Name
First Name
Last Name
Address
Street Address
City
,
State / Province
Zip / Postal Code
Phone number where you can be reached: (required)
Phone TypePhone Number (required)
Alternate phone number:
Phone TypePhone Number
Emergency Contact Number (if cannot be reached at above numbers)
Phone TypePhone Number
Pet's Name

Briefly describe the reason for your pet's visit:

How long has your pet had this illness or injury?
Hours
Days
Weeks
Months
Years


What is your pet's normal habitat?
Indoor only
Mostly indoor
Outdoor only
Mostly outdoor
In and out freely


Which of the following describes your pet's water consumption:
Drinks excessively
Not drinking
Same as usual
Drinking less
Drinking more


Which describes your pet's current appetite?
Very good
Good
Erratic
Picky
Poor
Very poor


Has your pet's appetite changed recently?
Yes, it has increased.
Yes, it has decreased.
No, it is about the same.


What is your pet's normal diet (including treats, table food, etc.) and how much does he or she eat?

Which best describes your pet's activity level?
Very active
Normal
Very inactive


Has your pet's activity level changed lately?
Yes, it has increased.
Yes, it has decreased.
No, it is about the same.


Have you noticed any changes in your pet's behavior lately? If so, please describe below.

Has your pet been showing signs of lameness lately? If so, which leg, and for how long?

If your pet is lame, which best describes the lameness?
Constant
Intermittent


Does your pet have difficulty rising?
Yes
No


Does your pet exhibit reluctance to jump or run?
Yes
No


Does your pet ever vomit? If so, how often? What is usually vomited?

If your pet is vomiting, is there any relationship to eating?
Yes, it occurs after meals.
No, there is no relationship.


Does your pet have diarrhea?
No
Occasionally
Yes


Is your pet straining to deficate?
Yes
No


Approximately how many bowel movements does your pet have each day?

Is your pet coughing?
No
Occasionally
Frequently


Is your pet sneezing?
No
Occasionally
Frequently


Does your pet have any nasal discharge?
No.
Yes, it is clear and watery.
Yes, it looks like pus.
Yes, it is bloody.


Does your pet have any discharge from the eyes?
No.
Yes, the right eye.
Yes, the left eye.
Yes, both eyes.


Has your pet been shaking his/her head or scratching at the ears?
Yes, but just shaking his/her head.
Yes, and scratching at the left ear.
Yes, and scratching at the right ear.
Yes, and scratching at both ears.


Is your pet itching excessively?
No.
Yes, but seasonally.
Yes, and it occurs year-round.


If your pet is scratching, where are the itchiest spots?

Please list any "lumps or bumps" that you have noticed on your pet:

Have you found any ticks on your pet recently?
Yes
No


Have you found any fleas on your pet recently?
Yes
No


Is your pet on heartworm preventative?
Yes
No


If your pet is on a heartworm preventative, which one do you give and how often is it given?

For cat owners only, has your cat ever tested positive for feline leukemia or FIV?
No.
Yes, feline leukemia.
Yes, FIV ("feline AIDS").


Please list any medications that your pet takes, including over-the-counter medications:

If it is necessary to send home medication with your pet, which do you prefer (if possible)?
Liquid
Tablets


Please list a phone number where you can be reached if necessary:

How much may we spend on your pet's diagnosis and treatments prior to calling you?

At what time do you plan to pick up your pet?

Powell Animal Hospital Drop-Off Policy:
Please note that we require all pets staying with us for the day to be current on vaccinations and to have had a negative fecal examination within the past 6 months. If your pet is due vaccinations, your pet will be vaccinated before treatments are performed. Additionally, your pet must be free from both external and internal parasites. If treatment for parasites is necessary, this will be performed at your expense.
Authorization:
By submitting this form, I authorize the doctors at Powell Animal Hospital to perform the diagnostics and treatments that they feel necessary up to the amount I listed above. I understand that if additional services are necessary, I will be contacted by a doctor so that we can discuss these procedures and their cost. If I cannot be reached, I give my permission for the doctors to perform any necessary emergency treatments that may be needed to stabilize a life-threatening condition. I agree to assume all financial responsibility for these treatments in the case of an emergency.
I have read the above statement, and I - (required)
Agree
Disagree



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