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Vomiting Questionnaire
APPOINTMENT
Vomiting Questionnaire
Please complete the form below prior to your appointment.
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Client Name
*
First
Last
Date
*
My cat is vomiting
*
Yes
No
When did the vomiting begin?
My cat last vomited
Describe the vomit (color, consistency, food present, foreign material, etc.)
Does the cat vomit within a few hours after eating?
Yes
No
How is your cat’s appetite (choose one):
Same
Increased
Decreased
Not eating at all
I don’t know
Water intake has (choose one)
Decreased
Increased
Is unchanged
My cat has not eaten since
I last offered food to my cat at
What was offered?
Have there been any diet changes in the past few months?
Yes
No
If so, what was the cat eating before?
My cat’s normal diet is:
What treats or other things does your cat eat or consume?
Is your cat acting normal?
Yes
No
If no, describe.
My cat has normal stools:
Yes
No
When was last BM?
My cat has lost or gained weight.
Lost
Gained
Is your cat coughing or gagging?
Yes
No
What, if anything, is produced?
What medications is your cat receiving?
Is it possible your cat may have eaten any plants, toys, hair ties, bones, insects, etc.?
Yes
No
If so, what do you think they may have eaten?
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 Number
*
Or Phone Number
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
*
Clear Signature
Date
*
Phone
Submit