Diagnostic Imaging Services

Abdominal and thoracic ultrasound – Hitachi Aloka Arietta 70

Computed tomography -Aquilion Prime

IDEXX ImageVue DR50 Digital Imaging System

Check in Form

Client name: *

Client primary phone number: *

Client secondary phone number:

Full client address (include postal code:) *

Client email address: *

Patient name: *

Species: *
CanineFelineOther

Breed: *

Patient age/birth date: *

Patient sex: *
MaleFemale

Has your pet been spayed or neutered *
YesNo

Health concerns today: *

What medications is your pet on? *

Does your pet have any allergies? *

Who is your family veterinarian? *

Referral Form

Referring Veterinarian Name: *

Hospital Name:

Veterinarian Email: *

Hospital Phone Number: *

Owner Name: *

Owner Phone Number: *

Owners Email: *

Address *

Pet Information

Pet's Name: *

Species: *
CanineFelineOther

Breed: *

Age/Birth date: *

Gender *
FemaleMaleFemale SpayedMale Neutered

Color: *

Dept. referring to *
EmergencyInternal Medicine/ImagingSurgery/DentistryReproduction

Medical History

Chief concern/Reason for referral *

Current Therapy/Medications *

Special Requests/Comments

History *

Lab work

Radiographs

** Reminder to attach patient history

Internal Medicine History

Prior to any appointment or recheck with the Internal Medicine Service clients must fill out this form.

Owner Name: *

Pet's name *

Email: *

Phone Number: *

Date of last visit: *

Presenting Complaint *

History

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? *

What is your pet's diet?

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 *

Please answer the following questions with Increased, Decreased, or Normal

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. *

Reproduction Form

We do not collect or breed every dog that is presented to us as it is our goal to only partner in helping to create healthy puppies. We will require breed specific health testing according to your breed's parent club. Requirements for each breed can be found at www.ofa.org/browse-by-breed

Client Name *

Address *

Primary phone number *

Secondary phone number *

Email *

Dog Information

Call name *

Reg'd name *

Breed *

Date of Birth *

Sex *

Colour *

Microchip/Tattoo# *

Registration # *

Registry *
CKCAKCOther

Advise of all health testing performed *

Diagnostic Imaging Services

Abdominal and thoracic ultrasound – Hitachi Aloka Arietta 70

Computed tomography -Aquilion Prime

IDEXX ImageVue DR50 Digital Imaging System

Get in Touch

Quick Links

Check in Form

Referral Form

Pet Information

Medical History

Internal Medicine History

History

What is your pet's diet?

Reproduction Form

Diagnostic Imaging Services

Abdominal and thoracic ultrasound – Hitachi Aloka Arietta 70

Computed tomography -Aquilion Prime

IDEXX ImageVue DR50 Digital Imaging System

Get in Touch

Quick Links

Newsletter

Check in Form

Referral Form

Pet Information

Medical History

Internal Medicine History

History

What is your pet's diet?

Reproduction Form