Resources, News & Pet Care Tips | Richmond Road Vet Clinic

Date

Client Name

Phone Number*

Patient Name

Emergency Phone Number

Why are you presenting your pet(s) for an exam today? Please include symptoms and duration.

Since you first noticed the symptoms, is your pet

Better
Worse
Same

Is your pet currently on medications?

Yes
No

When is the last time your pet was given medications?

Is your pet currently taking preventative for ticks/fleas?

Yes
No

Is your pet currently taking preventative for heartworm?

Yes
No

Do you Keep your pet(s)

Do you keep your pet(s)

Indoor
Outdoor

What type of food do you currently feed your pet?

When is the last time your pet has eaten?

Has your pet lost or gained weight recently?

No
Yes

How Much / What Period

Has your pet's water intake changed?

No
Yes

How Much / What Period

Has your pet's excretory habits changed?

No
Yes

How Much / What Period

Treatment Authorization
I hereby authorize Richmons Road Veterinary Clinic (RRVC) to perform medical and initial diagnostics/surgical procedures on this animal as required for diagnosis and treatment. Please be advised RRVC is not responsible for any personal belongings left with your pet. All pets must be free of fleas. If any are seen, the pet will be safely treated at the owner's expense. In the event of a medical emergency, our veterinarians will provide necessary and resonable medical care. Please provide emergency contact information above so that we may reach you in such an event.
Your pet will be seen on a priority basis. This will be based on the nature of the problem and the time your pet was dropped-off. If you are unable to pick your pet up by clinic closing time, you may be charged an additional boarding fee.
Financial Policy
Payment is due as services are rendered; the balance is due upon discharge from the clinic. Payments can be made by cash, personal check (with proper identification), Visa, Mastercard, Discover, American Express or Care Credit.

Name

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Patient Drop-Off Form

Patient Drop-Off Form

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