Is your pet coming in for a Procedure?

You can fill out this annual exam form and securely online by filling in the form below.

All questions with an asterisk after the question require an answer for this form to be submitted properly.

Client's Name *

First

Last

Email *

Patient's Name *

Procedure being done today? *

If the doctor thinks it's OK can we update your pet's overdue vaccinations? *

Yes
No
Will update later

Any changes in activity level?

Yes
No

Any changes in water consumption?

Yes
No

Any changes in appetite?

Yes
No

Any changes in urination?

Yes
No

Any changes in stool?

Yes
No

What medications are currently being given? Check that apply.

Additional details on other medications currently being given?

Layout

Date of last dose of Flea and Tick Preventative?

Type of last dose of Flea and Tick Preventative?

Has the patient been fasted?

Yes
No

Hours since last feeding?

Any new concerns?

Any questions about todays procedure?

Upload Pet's Photo

Click or drag a file to this area to upload.

Accepted file types: jpg, gif, png, pdf.

By clicking on the submit button below, I hereby authorize Plaistow-Kingston Animal Medical Center to perform such diagnostics, therapeutic and surgical procedures as described above. The nature of such services has been described to me to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the result or cure. I also authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I understand that I assume financial responsibility for all services rendered.

Pending Procedure Questions Form

Pending Procedure Questions Form

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