Medical Concern Form

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Owner Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Name *

First

Last

Phone *

Email *

What symptoms has your pet been experiencing?

Does your pet enjoy visiting the veterinary clinic?

Are there any concerns for the following: (check all that apply)

Increase in appetite
Decrease in drinking
Itching/Scratching
Vomiting
Excessive Sleeping
Skin Masses (explain below)
Other (explain below)
Decrease in appetite
Weight Loss
Shaking Head
Diarrhea
Scooting
Car Sickness
Increase in drinking
Weight Gain
Bad Breath
Urination Issues
Difficulty Rising
Behavioral Problem

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing? *

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them? *

No change
Worsened
Improved

experienced of enjoy

Has your pet experienced this problem in the past? *

Is your pet on any medications?

What kind of food do you feed your pet? *

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

If measured amount *

First

Last

Have there been any changes in appetite? *

Increased
Decreased
No change

Any increase or decrease in water consumption? *

Increased
Decreased
No change

Any change in bowel movements? *

Yes
No
Unsure

Does your pet spend time outside, even for walks or in the yard? *

Does your pet come into contact with other dogs? Please check all that apply *

Boarding
Grooming
Dog Parks
Other
None of the above

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

Was your pet last seen by Calhan Veterinary Clinic? *

Once the doctor has completed your pet’s exam, we will review the recommended treatment plan. I understand that financial responsibilities for services rendered are due at the time of discharge. *

I have read and understand

Drop off appointments: A drop off appointment is available if you are unable to wait at the practice for the duration of your pet’s visit. Please note that there is an additional charge for this service as your pet will be cared for and housed in a kennel until they are able to be picked up. If you need to leave your pet for their appointment, please inform the team member who greets you when you first arrive. *

I have read and understand.

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above-mentioned pet. *

I agree
I disagree

Signature *

First

Last

Date *

Ready for a visit?

We proudly serve the pets of Calhan, Peyton, Falcon, Simla, Ramah, Elbert, and surrounding areas. We look forward to seeing you and your pet. Request an appointment for your pet by clicking the button below!

Call to schedule

Location

13425 N Calhan Hwy,
Calhan, CO 80808

Working Hours

Mon – Fri: 8:00am – 5:00pm

Sat & Sun: Closed

Contact Info

(719) 347-2702

questions@calhanvet.com

After hours services may be available pending staffing. Please call (719) 347-2702 for availability.