Drop-off / Hospitalization Form

Far West Veterinary Clinic

3720 Far West Blvd Ste 101
Austin, TX 78731

(512)553-1833

farwestvet.com

We have arranged for you to leave your pet here to allow one of our doctors to examine your pet as soon as possible today. Please read through the following questions and answer any that may apply to your pet. Please be as detailed as possible; the more information we have the better we are able to treat your pet.

Owner/Contact Name: *(required)*

First Name (required)	Last Name (required)

Contact number you can be reached at today: *(required)*
Phone Type	Phone Number (required)

Alternate Phone (optional):
Phone Type	Phone Number

Pet's Name: (required)

When was your pet's last meal? (required)

What did he/she eat? (required)

My pet’s appetite is: (required)

Normal
Increased
Decreased

My pet's normal food is: (required)

Has your pet received any "human food" recently? (required)

What medications (if any) has your pet received in the last 24 hours? (required)

Does your pet receive any other medications on a regular basis? (required)

Yes
No

If so, what medication and what dose/frequency?

What Heartworm / flea medication prevention is your pet on and when was it last given? (required)

Is your pet sensitive or allergic to any medication or food? (required)

Has your pet ever had a vaccine reaction? (required)

Yes
No

Please describe the problem your pet is having, including pertinent history leading up to the current condition, and any previous major medical problems.

Is your pet lethargic? (required)

Yes
No

Water intake has.. (required)

Increased
Decreased
Unchanged

If your pet is vomiting, please list when it started, the color and the substance:

My pet last vomited..

My pet's stools are.. (required)

Normal
Constipated
Diarrhea

If Diarrhea - what color, consistency, and how frequently is it happening?

Has your pet eaten anything other than his/her food? (required)

Any known toxins? (required)

My pet has... (required)

Lost weight
Gained weight
Weight has stayed the same

My pet is... (required)

Limping
Sore
Has been injured
None of the above

I think his/her _____________ is bothering him/her:

Please give us any other important information that may help the Doctor in treating your pet. (required)

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