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West Lynn Animal Clinic

709 West Lynn
Austin, TX 78703

(512)482-8600

www.westlynnvet.com

Sick Pet Drop off Form

We have arranged for you to leave your pet here to allow Dr. Crawford, Dr. Faludi or Dr. Whitworth to examine your pet as soon as possible today. Please read through the following questions and answer any that may apply to your pet today. Please be as detailed as possible; the more information we have the better we are able to treat your pet.

Sick Pet Drop Off Form

Pet's Name - If multiple pets list them comma separated.

Your Contact Information

Name

First Name	Last Name

Phone
Phone Type	Phone Number

E-Mail Address :

Emergency Contact Information

Name

First Name	Last Name

Phone
Phone Type	Phone Number

Cell Phone Carrier

If provided will be used to send SMS messages to your cell phone instead of email.

Pet Diet Information

When was your pet's last meal?

What did he/she eat?

My pet's appetite is
Normal
Increased
Decreased

My pet's normal food is

Water intake has
Increased
Decreased
Unchanged

If provided will be used to send SMS messages to your cell phone instead of email.

Please provide name of medication, dosage amount and time given

Does your pet receive any other medications on a regular basis?
Yes
No

If so, what medication and what dose/frequency?

Has your pet ever had a vaccine reaction?
Yes
No

Is your pet sensitive or allergic to any medication or food?
Yes
No

If so, please provide details on pet allergy or sensitivity

Please describe the problem your pet is having, including pertinent history leading up to the current condition, and any previous major medical problems.

My pet is lethargic
Yes
No

My pet started vomiting... If your pet is vomiting. Include vomit color and substance

My pet last vomited

My pet?s stools are
Normal
Constipated
Diarrhea

If diarrhea, What color? What consistency? How frequently?

Has your pet eaten anything other than his/her food?

Any known toxins?

Lost or gained weight?

limping or sore or has been injured?

I think his/her ___ is bothering him/her.

Please give us any other important information that may help the Doctor in treating your pet.

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