Medical Concern Form

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Medical Concern Form

Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit. We will need to be able to contact you or someone with permission to make medical and financial decisions.
Please provide the information below so we may make the most of your scheduled appointment! Thank you!

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?

What are the concerns they have about their pet visiting the veterinarian?

If not, what are your concerns about the visit today?

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

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

If other, explain below *

When did the problem start?

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

No change
Worsened
Improved

Has your pet experienced this problem in the past? *

Is your pet on any medications? *

What medications is your pet taking?

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

If there has, for how long? Please elaborate. *

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? *

Information regarding adverse reactions

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

Many of our patients love peanut butter as a snack while visiting our office, but if you or your pet have an allergy to peanut butter, please let us know. Can your pet have peanut butter? *

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 *

Clear Signature

Date / Time *

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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!

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WHERE TO FIND US

13425 N. Calhan Highway,
Calhan, CO 80808

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Contact Information

P: 719-347-2702
E: questions@calhanvet.com

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Hours

Mon–Fri: 8:00am – 5:00pm
Sat: 8:00am – 12:00pm
(Open on the 1st and 3rd Saturday of the month.)
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Name