IF YOUR PET IS EXPERIENCING ANY *vomiting/diarrhea/coughing/sneezing* PRIOR TO THE APPOINTMENT PLEASE CALL IMMEDIATLY AS WE MAY HAVE TO RESCHEDULE THE APPOINTMENT

Pet's Name *

Today's Date *

YYYY

Best contact number for the day of your appointment *

Name of Pet Insurance provider (if any)

Did your veterinarian refer you today? *

Yes

If no, who referred you?

Name of Regular Veterinarian *

Vet Clinic Name *

Please list all other Veterinary hospitals that have radiographs (x-rays) and records

Reason for today’s visit *

(please be specific)

Left Forelimb

Right Forelimb

Left Rearlimb

Right Rearlimb

Other (write below)

Other *

(write NA if does not apply)

If your pet is showing lameness, how long has it been present? *

(write NA if does not apply)

Is lameness worse during or after exercise? *

Yes

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

Yes

What treatments has your pet had to address the current lameness issues? *

(write NA if does not apply)

Has your pet improved with treatment?

Yes

What is the patient's current level of activity/exercise? (please describe) *

Comments regarding how the injury occurred if known

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

If Yes, what is the dose (mg), duration of treatment and when was the last dose administered? *

(write NA if does not apply)

List all other medications/injections/supplements your pet has had within the last 30 days *

(write NA if does not apply)

Does your pet have any existing medical conditions or has he/she had previous surgeries elsewhere? *

*Note: If your pet has been recently diagnosed with an infectious disease we will ask for proof of negative lab results or clearance from your primary vet before we can see your pet.

Does your pet have any allergies to foods, medications or any previous sensitivities to sedatives or anesthetic drugs? *

(write NA if does not apply)

Has your pet had any vomiting/diarrhea/coughing/sneezing in the last 30 days? *

Does your pet have any behavioral issues? (Dog Aggression, Blanket Chewing, Cage Biting) ? *

Will your pet have anything to eat on the day of the appointment? If Yes, at what time? *

**Note: Patients must have fasted 4 hours prior to appointment if any diagnostics are recommended the day of the appointment.

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

Please call prior to any treatments

I assume all financial responsibility for the fees related to these procedures and will provide full payment at the time my pet is discharged from The Sams Clinic

If fields are left empty the form will not submit and text will turn red to complete

Have you had a fever or any symptoms of illness in the last 14 days? Have you been exposed to anyone testing positive for Covid-19 in the last 14 days? *

Please answer yes or no to both questions *Symptoms of the illness include (but is not limited to) Cough Fever (> 100 F) Sore throat Headache Congestion GI issues (vomiting, diarrhea, nausea) Body aches Loss of smell or taste Any general feeling of illness

Write/sign your name and date below *

Thank you!

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Your Pet’s Appointment

The Sams Clinic

Location
489 Miller Avenue
Mill Valley, CA 94941

Phone: (415) 380-0500
Fax: (415) 380-0504

Email: info@thesamsclinic.com

Clinic Hours

Monday:   8:00 a.m. - 5:00 p.m.
Tuesday:   8:00 a.m. - 5:00 p.m.
Wednesday:   8:00 a.m. - 5:00 p.m.
Thursday:   8:00 a.m. - 5:00 p.m.
Friday:   8:00 a.m. - 12:00 p.m.
Saturday:   Closed
Sunday:   Closed

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Patient History Form

INITIAL CONSULT INTAKE FORM

IF YOUR PET IS EXPERIENCING ANY *vomiting/diarrhea/coughing/sneezing* PRIOR TO THE APPOINTMENT PLEASE CALL IMMEDIATLY AS WE MAY HAVE TO RESCHEDULE THE APPOINTMENT

Pet's Name(required)

Today's Date(required)

Best contact number for the day of your appointment(required)

Name of Pet Insurance provider (if any)

Did your veterinarian refer you today?(required)

Yes

If no, who referred you?

Name of Regular Veterinarian(required)

Vet Clinic Name(required)

Please list all other Veterinary hospitals that have radiographs (x-rays) and records

Reason for today’s visit(required)

(please be specific)

Left Forelimb

Right Forelimb

Left Rearlimb

Right Rearlimb

Other (write below)

Other(required)

(write NA if does not apply)

If your pet is showing lameness, how long has it been present?(required)

(write NA if does not apply)

Is lameness worse during or after exercise?(required)

Yes

Is lameness worse when rising/getting up after laying down?(required)

Yes

What treatments has your pet had to address the current lameness issues?(required)

(write NA if does not apply)

Has your pet improved with treatment?

Yes

What is the patient's current level of activity/exercise? (please describe)(required)

Comments regarding how the injury occurred if known

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)?(required)

Metacam/Meloxicam/Meloxidyl

Rovera/ Carprofen/Rimadyl

Galliprant

Previcox

Other NSAID or Steroid

NONE

If Yes, what is the dose (mg), duration of treatment and when was the last dose administered?(required)

(write NA if does not apply)

List all other medications/injections/supplements your pet has had within the last 30 days(required)

(write NA if does not apply)

Does your pet have any existing medical conditions or has he/she had previous surgeries elsewhere?(required)

*Note: If your pet has been recently diagnosed with an infectious disease we will ask for proof of negative lab results or clearance from your primary vet before we can see your pet.

Does your pet have any allergies to foods, medications or any previous sensitivities to sedatives or anesthetic drugs? (required)

(write NA if does not apply)

Has your pet had any vomiting/diarrhea/coughing/sneezing in the last 30 days? (required)

Does your pet have any behavioral issues? (Dog Aggression, Blanket Chewing, Cage Biting) ?(required)

Will your pet have anything to eat on the day of the appointment? If Yes, at what time?(required)

**Note: Patients must have fasted 4 hours prior to appointment if any diagnostics are recommended the day of the appointment.

Owners Consent to Treatment(required)

Yes

Please call prior to any treatments

I assume all financial responsibility for the fees related to these procedures and will provide full payment at the time my pet is discharged from The Sams Clinic

If fields are left empty the form will not submit and text will turn red to complete

Have you had a fever or any symptoms of illness in the last 14 days? Have you been exposed to anyone testing positive for Covid-19 in the last 14 days?(required)

Write/sign your name and date below (required)