Today's Date *

MM

DD

YYYY

Did your veterinarian refer you today? *

Yes

No

Reason for today’s visit *

(please be specific)

Left Forelimb

Right Forelimb

Left Rearlimb

Right Rearlimb

Other (write below)

Is lameness worse during or after exercise? *

Yes

No

Is lameness worse when rising/getting up after laying down? *

Yes

No

Has your pet improved with treatment?

Yes

No

Has your pet been on any of the following anti-inflammatory or steroid medications: Metacam, Meloxicam, Galliprant, Previcox, Rimadyl, Carprofen (If yes, which one(s)? *

Metacam/Meloxicam/Meloxidyl

Rovera/ Carprofen/Rimadyl

Galliprant

Previcox

Other NSAID or Steroid

NONE

Owners Consent to Treatment *

We will call prior to diagnostics unless consent to proceed without notification is given at the time of drop-off. The doctors and/or technicians may need to administer a sedative, take x-rays, and/or perform blood work to diagnose your pet’s ailment. Do you consent to these procedures?

Yes

No

Please call prior to any treatments