Date: *

Client Name: *

First

Last

Patient Name: *

Is the cat urinating outside the box? *

Yes
No

If so, where?

How long has he/she been going there?

Is the cat defecating outside the box? *

Yes
No

If so, where?

How long has he/she been going there?

How many litter boxes are there? *

How many of the litter boxes are covered? *

Where are the boxes? *

What kind of litter do you use? (Check all that apply) *

Scoopable (sand-like that clumps when wet)
Clay (larger pieces that do not clump when wet)
Other (please list)

Scoopable. Please list brand and if the litter is scented or unscented.

Clay. Please list brand and if the litter is scented or unscented.

How often do you scoop out the litter box? *

How often is the box completely emptied and fresh litter put in? *

Are liners used? *

Yes
No

Are they scented? *

Yes
No

How deep is the litter in each of the boxes? (Approximate inches) *

Are deodorants such as baking soda used in the box? *

Yes
No

If so, describe:

How many cats in the household are using these boxes? *

What does the cat do in the litter box: does he/she go in and out several times before voiding, does he/she dig in or outside the box, etc.? *

Have you changed types of litter being used in the past six months? *

Yes
No

If so, describe:

Have you changed brands of litter in the past six months? *

Yes
No

If so, describe:

Have you seen the cat going outside the box? *

Yes
No

Please describe what he/she is doing.

Have there been any changes to the household in the past few months? *

Yes
No

If so, describe:

How many cats are in the household? *

How many dogs are in the household? *

Is the cat acting aggressive to other members of the house? *

Yes
No

Is the cat acting aggressive to other pets in the house? *

Yes
No

If your cat is acting aggressive, please describe the behavior below:

Is your cat's appetite normal? *

Yes
No

If not, is it eating at all? *

Yes
No

What have you been feeding your cat during the last week? (Include dog or cat foods, treats, tablefoods, milk, and anything else that it gets on a daily basis. Also state what percentage of the diet is each item or category.) *

Does your cat have access to foods other than what you feed it? *

Yes
No

If so, what? *

Has there been a significant diet change in the last few weeks? *

Yes
No

If so, does that correspond with the onset of the housesoiling? *

Yes
No

Do you have any other behavioral concerns about your cat? *

Yes
No

I hereby authorize The Cat Doctor of Monroe and Dr. Kimberly Scutchfield to perform care for my pet. I acknowledge that I am the owner/appointed caregiver of the animal described above and am legally able to consent to care for my pet. I understand that any procedure poses a risk to my pet regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I further authorize The Cat Doctor of Monroe and staff to release my pet's medical records to another veterinary provider if requested by another veterinary provider.

I understand staff will contact me after they have examined my cat to discuss recommended diagnostics and treatment and will provide an initial estimate of charges. I can be reached at

Phone: *

Or Phone:

If I cannot be reached at this number, I authorize initial diagnostics - including radiographs and blood work if indicated for my cat. Further, if I cannot be reached, I authorize initial treatment - including fluid support and other supportive medications as indicated for my cat. If I cannot be reached, I authorize sedation if needed for treatment either due to the nature of the problem or my cat’s aggression. I understand that sedation and anesthesia pose a risk to my pet, regardless of health status. If my cat is dropped off, I understand my cat will be treated for fleas if evidence of infestation is found today and I will be responsible for that cost.

I understand payment is due when my cat is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for my cat.

Payment is expected at the time of service. How will you be paying today? *

Cash
Credit/Debit
Check
Care Credit - minimum $200 transaction

Signature *

Date *

Housesoiling Questionnaire

Housesoiling Questionnaire