Dauphin Vet Clinic

PO Box 556
Dauphin, MB R7N 2V4

(204)638-3044

www.dauphinvetclinic.com

Patient Drop-Off Form (History)

Patient History Form
Please provide as much information and as accurately as you can to help us provide your pet with the best care we can. If you are unsure of an answer, please just say so.
Owner Name (required)
First Name (required)
Last Name (required)
Patient name (required)

Clinic where appointment is booked. (required)
Dauphin Vet Clinic
Ste. Rose Vet Clinic


What is the purpose of this visit?
What symptoms are you seeing? How long has the problem been present? Is it getting better or worse or staying the same?
Please respond: (required)

Do you have other animals at home and are they sick as well?

Question
Has your pet undergone any surgery or trauma (such as hit by car or something else) that may be connected to the current problem? If yes, what was it and when did it occur?
Please Respond

Is your pet up to date with vaccinations?
Yes
No
Please vaccinate if possible


Has your pet been previously diagnosed with an illness/disease?

Is your pet currently on any medications? Which ones and how often?

What is your pet's diet? Please be specific and include treats.

Any changes in energy or activity level? Please be specific.

Any known allergic reactions to certain medications?

Any changes in drinking or eating habits? Please be specific.

Any changes in urination or defecation? Please be specific.

Any behavioural issues? Changes? Please be specific.

Any skin issues, including lumps? Please be specific.

Phone # where we can reach you with questions. (required)
Phone TypePhone Number (required)
Diagnostics
If needed, further diagnostics could be done to help us provide the best care for your pets. Please answer the following options.
Bloodwork (approx. $115) (required)
YES
NO
Call First


Skin scrapings for skin issues (up to $55) (required)
YES
NO
Call First


X-rays (first one $106, additional ones $31 each) (required)
YES
NO
Call First


Urinalysis ($47.50) (required)
YES
NO
Call First


Special testing that needs to be sent to a special lab (required)
YES
NO
Call First


Acknowledgement
Please note: There will be an exam fee of $65. If you responded no to all the above, your pet may need to go home and come back another day for further testing. By clicking Submit, you are giving permission to examine your pet and acknowledge that you will pay for services whether by Cash, Cheque, Credit or Debit and you are confirming that the above information is accurate to the best of your knowledge.

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