*Owner's Name

*Address

*City, State, Zip Code

*Phone

Alternative Phone

*Name

*Age

Sex

*Species and Breed

First, tell us briefly what is going on with your animal:

General Questions:
When was your animal last dewormed and with what product?

What feed does your animal eat and how much?

Any supplements?

What type of hay/pasture and how much per day?

Has your animal had any medical concerns in the past / any history of illness besides conditions we have treated him/her for? If so, please explain:

How long have you owned this animal?

Describe this animal’s living conditions: (example: goat lives in a herd of 5 other goats on a 3 acre fescue pasture)

Is this animal able to be easily handled and do you have handling facilities suitable for restraint for a vet exam and treatment?

Please describe: Example: the cow will be in a small pen with a squeeze chute available or the goat is friendly and will approach people to be haltered for examination

*Primary Concern Today

Duration of symptoms

Getting better/worse?

*How is the animal feeling?

Appetite

For how long?

Drinking/Urination

For how long?

Any diarrhea?

Specify how many time/how many days

Any coughing or nasal discharge in the past two weeks?

Any lameness/limping or other signs of pain?

Has your animal had a similar problem in the past?

Please list all the medications you are currently giving your pet and how frequently you are giving them. Please list even if you were prescribed them by us as we want to confirm your pet is still receiving them. Please note if your pet has missed any doses within the past week and when it was missed. List the times you last gave each medication. (example: Furosemide 12.5 mg 1 tab once daily, last given at 8am today, one dose missed yesterday morning)

Is there anything else we need to know/any questions that you have?