Diagnostic Imaging Services

Owner Name: *

Pet's name *

Email: *

Phone Number: *

Date of last visit: *

Presenting Complaint *

Name of regular veterinary clinic: *

When was your pet last vaccinated? *

When was your pet last dewormed? *

If your pet has travelled outside Alberta, where and when? *

Does your pet live *
Indoors onlyIndoor/OutdoorOutdoors only

What other animals does your pet have contact with? Do they have health concerns? *

Does your pet have any allergies? If yes to what? *

Brand? *

Amount given in cups or cans? *

# of meals per day *

Treats *

Supplements *

Recent changes in diet? If so when and what was the previous food? *

Please list previous illnessess *

Please list any previous surgeries *

Please list all medications that your pet is currently taking or within the last week. (prescription and over the counter) *

Symptoms *
CoughingSneezingWheezingVomitingDiarrheaSeizuresLimpingAbnormal behaviourSkin masses or lumps notedOdor to breathTrouble BreathingFaintingLoss of BalanceRunny Nose/EyeScratchingChange in voiceLethargyTremorsWeaknessNone of the above

Explain symptoms *

My pet's energy level is: *

My pet's weight is: *

My pet's appetite is: *

The amount of water my pet is drinking is: *

The number of stools each day is: *

My pet's urination frequency is: *

Amount of urine passed each time is: *

Has the color of your pet's urine changed? *
YesNoUnsure

If Yes, what color? Any blood? Any Straining? *

Is your pet vomiting? *
YesNoUnsure

If Yes, is it Food, Water, Blood, or Foam? *

Does your pet have Diarrhea? *
YesNoUnsure

If Yes, is it bloody, black tarry, mucous foamy, large volume, small volume, associated with straining *

Does your pet historically have anal gland problems? *

Does your pet have or had previous skin conditions or ear problems? If so what treatments? *

Please list any questions or comments you have below. *

I authorize the staff at Trinity Hills 24 Hour Veterinary Hospital to use the following; Images and/or videos of my pet, my pets name/ medical conditions, on their social media platforms (Facebook, Instagram, and Tik Tok) *
YesNo

Owner Name: *

Pet's name *

Email: *

Name of regular veterinary clinic and veterinarian

If you pet has travelled outside of Alberta, where and when? *

What is your pets current diet?

Amount per meal and number of meals per day *

Has there been a change in appetite or water consumption? *
Increased waterIncreased foodDecreased waterDecreased foodNo change

Treats (kind and amounts)

Please list all supplements *

Recent changes in diet? If so, when and what was the previous food?

Please list all medications (current or in the last 7 days)

Please list any symptom(s), and explanation(s)

Has there been a weight change *
IncreasedDecreasedNo change

Please list any questions or comments you would like addressed at your appointment.

Pet name *

Client name *

Email *

Best number(s) to be reached at for surgery day

Date of surgery *

Please list all procedures that you are expecting to be performed on your pet. If applicable, please specify which leg (e.g. left front) and the location of any masses to be removed. *

If you would like the following added on (at no additional cost) please select: *
Ear pluckingAnal Gland ExpressionNail Trim

Has there been any change in your pet’s condition since your last appointment? YES / NO. If yes, lease describe: *

Appetite *
NormalAbnormal
If abnormal, please describe

Vomiting *
YesNo

Stools/defecation *
NormalAbnormal
If abnormal, please describe

Coughing *
YesNo

Urination *
NormalAbnormal
If abnormal, please describe

Energy level *
NormalAbnormal
If abnormal, please describe

Has your pet’s weight changed recently *
IncreaseDecrease
If yes, please describe

Has your pet ever had general anesthesia performed before? *
YesNo
If yes, did your veterinarian report any complications during anesthesia or recovery period?

To your knowledge, is your pet allergic to any medications? *
YesNo
If yes, please list:

Please list all medications and supplements given, strength of medication, prescribed timing, most recent dose given (including time).

E.g. Benazepril 2.5mg twice daily. Last dose at 7am this morning

Current diet

Amount

Frequency

Does your dog have any special commands for bathroom breaks? *
YesNo
If yes, please describe:

Does your cat have any special needs for the litter box? E.g. Covered/uncovered, clay, pellets, etc? *
YesNo
If yes, please describe: