Client Name *

First

Last

Cat's Name *

What care is due for your cat today? *

Is there another clinic we should call for records? If so, what clinic?

Do you have any concerns today? *

What medication(s) is your cat receiving?

What flea prevention do you give your cat? Date of last dose?

What heartworm prevention do you give your cat? Date of last dose?

What is your cat's normal diet? (Brand, canned, dry, how often, etc) *

Has your cat been vomiting? *

Yes
No

Has your cat had diarrhea? *

Yes
No

Has your cat been coughing? *

Yes
No

Has your cat been sneezing? *

Yes
No

Any change in appetite? *

Yes
No

Any change in behavior? *

Yes
No

Please select all that apply to your cat's lifestyle: *

My cat stays strictly indoors and never goes outside
My cat is allowed outside on a leash or under supervision for short periods of time
My cat is allowed inside or outside at their pleasure without supervision
My cat is strictly outside without regular direct supervision

Would you like a nail trim for your cat today (indoor only cats)?

Yes
No

Do you need heartworm prevention for your cat?

Yes
No

Do you need flea prevention for your cat?

Yes
No

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

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

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 *

Wellness Exam Questionnaire

Wellness Exam Questionnaire

Location

Contact Us

Hours

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

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