Medical Treatment Consent Form | Animal Kingdom Veterinary Hospital

Owner's Name*

Today's Contact Phone*

Pet's Name*

Primary Problem*

GI:

Vomiting

Diarrhea

Not eating

Weight Loss

Change in eating habits

(please check all that apply)

Duration of Symptoms:

Skin:

Itching/scratching

Bumps

Hair loss

Growth/tumor

(please select all that apply)

Duration of Symptoms:

Ears:

Head shaking

Scratching

Redness/discharge

(please select all that apply)

Duration of Symptoms/Is it Left Ear Right Ear or Both:

Urinary:

Frequent urination

Blood in urine

Unable to urinate

Urination in unusual places

Changes in drinking habits

(please select all that apply)

Duration of Symptoms:

Eyes:

Discharge

Redness

Other

(please select all that apply)

Duration of Symptoms:

General:

Lethargy

Duration of Symptoms:

Respiratory:

Coughing

Sneezing

Difficulty breathing

(please select all that apply)

Duration of Symptoms:

Musculoskeletal:

Limping

Slow to get up

Back pain

(please select all that apply)

Duration of Symptoms/For limping, which leg or paw is affected?

Current Medications:*

Other Services You'd Like Performed:

Nail clip

Ear cleaning

Express anal glands

Microchip

(additional charges apply)

Digital Signature:

Date

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