Your name *

First Name

Last Name

Phone *

Please enter the cell phone number you can be reached at during your pet's appointment.

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Gastrointestinal symptoms *

Please select all that apply

Vomiting (food)

Vomiting (bile / fluid)

Diarrhea

Loose stool

Blood in stool

Distended abdomen

Inappetence / loss of appetite

None

Urinary symptoms *

Please select all that apply

Straining / unable to urinate

Blood in urine

Increased urination

Increased drinking

Urinating in inappropriate places

None

Respiratory symptoms *

Please select all that apply

Respiratory distress

Coughing

Sneezing

Hacking / clearing throat

None

Injury / trauma *

Please select all that apply

Bite wound (inflicted by known animal)

Bite wound (inflicted by unknown animal)

Laceration

Lameness / limping

Pain

Swelling

None

Neurological symptoms *

Please select all that apply

Seizures

Hind-end weakness / collapse

Paralysis

None

Has your pet been seen elsewhere for this issue? *

No

Yes

Consent to diagnostics / treatment *

Having approval for diagnostics (i.e. x-rays for a dog who is limping, or bloodwork and x-rays for a cat that has been vomiting) allows us to expedite your pet's appointment, so that treatment can begin sooner. Please select from the following options to indicate which diagnostics you approve for your pet. Diagnostics will only be performed if the attending doctor feels they are relevant to the symptoms your pet is experiencing, and necessary for a diagnosis to be made. Once your pet has been examined and diagnostics have been reviewed, your pet's doctor will call you with an update and treatment plan. If your pet's symptoms require hospitalization, a doctor will discuss your options for care with you. Depending on the nature of your pet's illness or injury, their care may require additional diagnostics and/or treatments.

Examination ( $94.00 )

Blood work ( $210.00+ )

X-ray imaging ( $135 - $444+ )

Ultrasound imaging ( $125- $414 )

Hospitalization + treatment if warranted

Consent agreement *

I consent to the examination of my pet by the veterinarians at Laytonsville Veterinary Practice. I agree that after consultation with me the doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and /or perform surgery on my pet. I understand there are always risks with sedation and/or surgery and that I am encouraged to discuss any concerns I have with the attending veterinarian before the procedure is initiated.

*

I understand that the veterinary care during the night time and weekend hours is provided at the discretion of the attending veterinarian. Continuous presence of personnel may or may not be provided during these hours. We do not have continuous 24 hour supervision for all cases.

*

I understand that diagnostics and treatments incur additional fees in addition to examination, and request the aforementioned be done at the discretion of the attending doctor. I understand that my pet's appointment is being worked into our schedule on an emergency basis, and may incur a $55.00 emergency triage fee.