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Hospital History Form
The purpose of this form is to allow our doctors to be more informed when they first examine your pet in the hospital. We will want to reach you by phone once that initial assessment of your pet is complete so that we can discuss findings and our recommendations. Please read this form all the way to the end, where we have outlined our COVID hospital policies.
Owner's Name:
First
Last
Email:
Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Patient Name:
Owner Presenting Pet:
Best Contact Phone:
Please provide the name and number of the person who we should contact once our veterinarian has examined your pet. Our team will advise as to whether you should wait at the clinic or leave to allow us to contact you later.
Presenting complaint: Why are we seeing your pet today?
Please upload photo if applicable:
Drop files here or
How long has the problem been going on? And, since you first noted the issue is your pet getting better, staying the same or getting worse? Please describe symptoms and duration.
What is your pet’s normal diet and amount fed (brand, amount and frequency)?
When was the last time you fed your pet?
Is your pet on any medications? Please describe:
Is your pet taking any supplements or herbal remedies? Please describe:
Is your pet having difficulty going to the bathroom?
Urination normal
Urination abnormal
Defecation normal
Defecation abnormal
Please describe:
Is your pet eating and drinking normally?
Eating normal
Eating abnormal
Drinking normal
Drinking abnormal
Please describe:
Please check any of the following if they have been seen:
Coughing
Sneezing
Trouble Breathing
Vomiting
Low Energy
Weakness
Lump on body - where?
Limping - which limb?
Shaking head
Scratching - please describe where and indicate level on scale 0 (none) to 10 (terrible)
Pain - please describe where and indicate level on scale 0 (none) to 10 (terrible)
Please describe any of the above symptoms:
Is your pet due for any routine services such as vaccines (please check one option)?
Not sure
No
Yes - please discuss
Yes - update if possible
Other concerns or requests of our team:
Please check one of the following:
*
The veterinarian is authorized to administer or dispense all items listed above as well as any other treatments or diagnostics the vet deems necessary without further authorization on my part.
The veterinarian MUST CALL ME BEFORE performing or administering any treatments or diagnostics BEYOND A PHYSICAL EXAM.
Consent
*
I agree to the COVID-19 examination policy.
I understand that during the performance of these procedures, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect Eglinton Veterinary Facilities to use reasonable care and judgement in performing the procedure(s). The nature of the procedure and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding my pet.
• Our front door will remain locked and only opened by a team member once a discussion is had over the phone.
• When you arrive, PLEASE DO NOT KNOCK ON WINDOW OR DOOR. PLEASE CALL us at 416-487-1533 so a staff member can advise you of the next steps. Be patient as our phone lines may be busy due to higher call volumes.
• For ALL APPOINTMENTS: pets will be admitted to the hospital one at a time. Owners do not enter the building.
• Our veterinarians will examine pets away from their owner(s) and will call owners with treatment plans so please have phone(s) available at all times.
• We will ask that all invoices be paid before returning or when you return to the clinic. We accept VISA or MASTERCARD over the phone, DEBIT, VISA and MASTERCARD on site at the Clinic and INTERAC E-TRANSFERS sent to info@eglintonvet.com (NO CASH OR CHEQUES)
• For FOOD AND/OR MEDICATION PICK-UP: we will invoice you over the phone and charges will be billed as above during pick up. If you are not comfortable with the above policies and protocols, please call or e-mail us to cancel or reschedule your upcoming appointments.
About
Our Hospital
Meet the Team
Where to find us
Drop off Appointments
Services
Wellness and Vaccination Programs
Preventive Services
Laparoscopic procedures
Laser Therapy
Medical Services
Surgical Services
Nutritional Counseling
Pet Supplies
Additional Services
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
Pet Portal
Pet Portal
General Store
Contact
Request an Appointment
Refill Requests
Hospital History Form
Blog