Drop Off Questionnaire in Caldwell, TX | Caldwell Veterinary Clinic

Name on File*

First Last

Name of Pet*

Pet's Name

Phone to reach you at*

Drop off Date*

Pickup Time*

:

Why are you dropping your pet off?*

Select all that you want your pet to recieve*

Vaccines
Nail Trim
Anal Glands expressed

What species are you dropping off?*

Do you approve the recommended annual exam for dogs at $145*

This includes: Wellness Exam, Rabies, DA2PP/L4 (combo), Bordetella Oral, Heartworm Test, and a Fecal

Do you approve the recommended annual exam for cats at $160*

This includes: Wellness Exam, Rabies, Felocell CVR, Leukemia Vaccine, Leuk/FIV/Heartworm Test, and a fecal.

What are you wanting done with your large animal?*

Please select all that apply regarding Monthly meds*

My pet is NOT on any monthly meds
My pet is on Heartworm prevention
My pet is on Flea/Tick prevention

What Monthly meds do you give?

What is Wrong with your pet?*

When did problem first start?*

Has condition improved or worsened since starting?*

Have you tried any treatment for this problem?*

If yes with another vet, you can upload the files below.

What treatment did you use and what were the results?*

Upload previous records here

Max. file size: 512 MB.

Is your pet inside/outside/both?*

What do you feed your pet?*

Please select all that apply regarding food/treats*

I have NOT changed my pet's food
I HAVE changed my pet's food
My pet does NOT get table scraps
My pet DOES get table scraps
My pet does NOT get treats
My pet DOES get treats

Is your pet's vaccines current?*

Was your pet previously vaccinated through us?*

You can upload previous records below if not vaccinated with us

Upload Records here

Max. file size: 512 MB.

Other Information Neccessary

Please answer normally, or pick the best 'abnormal' answer for the following questions.

Eating*

Normally
Less
More
Pickier

Drinking*

Normally
Less
More

Acting*

Normally
Lethargic
More energized
Abnormally

Urinating*

Normally
Less
More

Defecating*

Normally
Runny/Diarrhea
Hard Stools
Abnormally

Sleeping*

Normally
Less
More

Seeing*

Normally
Less
Abnormally

Breathing*

Normally
Shallow
Heavy

Vomitting*

Yes
No

Coughing/Gagging*

Yes
No

Scratching*

At Skin
At Ears
Chewing at Tail head
Chewing at Feet
Chewing at 'flank area'
None of the above

Shaking Head*

Yes
No

Have Hair loss*

Yes
No

Weight*

Same
Loss
Gain

Limping*

Yes
No

Which Leg/paw*

Please specify

Behavior Problems*

Yes
No

Describe Behavior issues

If you already have prior to, disregard

Showing signs of pain*

Yes
No

Have eye problems*

Yes
No

Does abdomen feel enlarged*

Yes
No

Final Information

Would you like us to call prior to doing any treatments or tests?*

Phone Number to call*

Bloodwork Approval

By clicking the box, I am approving bloodwork and its associated cost.

A full blood panel can cost up to $105. A blood panel allows us to recognize underlying abnormalities easier. While we may run a smaller, specified blood test under the $105 amount, if you are uncomfortable with this, we will call you and discuss this option if we feel it is necessary.

Radiograph Approval

By clicking the box, I am approving up to 4 radiographs and its associated cost

Radiographs can help us narrow down the issue being experienced with your pet. Four radiographs can cost up to $187. We may not need 4 radiographs, but to get different angles, it may be necessary. If we need more views, we will call you.