Client *

First

Last

Cat Name

Drop-Off Examination

Please read through the following questions, and answer any that may apply to your cat today. The more thorough and accurate you are, the better we can care for your cat.

Everything was okay with my cat until: *

Since then: *

My cat is lethargic *

Yes
No

Water intake has *

Decreased
Increased
Is unchanged

Food intake has *

Decreased
Increased
Is unchanged

My cat has not eaten since: *

I last offered food to my cat at: *

Date

Time

What was offered? *

What brand and variety of food(s) do you normally feed? *

What treats or other things does your cat eat or consume? *

Has your cat had access to foods other than its normal cat food? *

Yes
No

If yes, please specify:

My cat is vomiting: *

Yes
No

When did the vomiting begin?

How frequently is your cat vomiting?

My cat last vomited:

Describe the vomit (color, consistency, food present, foreign material, etc.)

My cat has normal stools: *

Yes
No

My cat seems constipated: *

Yes
No

When was last BM? *

My cat started having diarrhea: *

Yes
No

How long has your cat had diarrhea?

How many episodes of diarrhea per day?

Please describe the diarrhea (color, consistency, mucus, etc.):

My cat is having difficulty urinating: *

Yes
No

My cat has: *

Lost weight
Gained weight
Weight is stable

Is your cat coughing or gagging? *

Yes
No

What, if anything, is produced?

Is your cat sneezing? *

Yes
No

Is there any discharge from nose or eyes? *

Yes
No

My cat is: *

Limping
Sore
Has been injured
N/A

Describe the situation: *

What do you think is bothering him/her? *

It has: *

Worsened
Remained the same
Improved some

This has happened: *

Never before
Recently
Is a longtime (chronic) problem

Please describe in your own words what you think is the problem: *

What medications is your cat receiving? *

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.

Signature *

Date *

Sick Exam History

Sick Exam History

Location

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Hours

We are a cat-only veterinary hospital in Monroe, MI.

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