Hospital History Form

Owner's Name:

First Last

Email:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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:

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.

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