Date Date Format: MM slash DD slash YYYY Cat’s NameD.O.B. / AgeWhat are we seeing your pet for today? Annual Exam Other If other. please let us know why below:Current Medications: Yes No If yes, please list the medicationsHas your pet had any of the following problems?:CoughingSneezingVomitingUnusual VocalizationPet Withdrawn/HidingIncreased Thirst or UrinationLethargyDepressionDiarrheaPoor AppetiteWhat is your cat’s diet? (Brand, type, frequency)If Dr. Flynn would like to do blood work to diagnose your pet, do you authorize this?YesNo(Depending on your pet’s age, bloodwork runs between $82-$117)If Dr. Flynn would like to take digital radiographs, do you authorize this?YesNo(Depending on number of shots needed, price usually ranges from $100-$140, price may increase if additional shots needed.)I hereby authorize and direct Dr. Dorothy V. Flynn D.V.M. to perform the procedure(s) noted above (or if mutually agreed upon over the phone) and to administer anesthetics and/or other drugs deemed advisable for the health and safety of my cats(s) if deemed necessary. I understand the nature of the procedure(s) and the relative risks involved. I authorize The Cat Clinic of Destin to provide any appropriate care should an unexpected complication arise. (PLEASE NOTE THAT IF ANY LIVE FLEAS ARE SEEN ON YOUR CAT TODAY, WE WILL GIVE ORAL CAPSTAR, APPLY TOPICAL DEWORMER AND APPLY TOPICAL FLEA TREATMENT AND ANY RESULTANT CHARGES WILL BE APPLIED TO YOUR BILL.)SignatureDate Date Format: MM slash DD slash YYYY Chart Number (clinic use)CAPTCHA
