SOUTHEAST GEORGIA VETERINARY CLINIC

104 CANDLER DR
BRUNSWICK, Georgia 31523

(912)554-8388

www.southeastgeorgiavetclinic.com

Sick Patient Form

Pet's Name

Vomiting (mark all that apply):
Food
Blood
Phlegm
How often?

Diarrhea (mark all that apply)
mucus
blood
straining
How often?

Eating (mark all that apply):
More
Less
Eating foreign objects
How long?

Drinking
More
Less
How long?

Urination:
painful
Blood noticed
straining
not urinating
excessive urination
How long?

Sneezing/Coughing:
any discharge
difficulty in breathing
dry hacking cough
congested cough
How often is the coughing and/or sneezing?

EYES
Which one?

How long?

Color & consistency of discharge if present

Ears
Which one?

How long?

Mark all that apply:
itching
odor
discharge
Describe discharge if present

Skin
Mark all that apply
itching/irritation
hair loss
fleas
family members itching
How long has patient been itching? Is it seasonal?

Have you used any new shampoos, dips or topical medications?

Did you have anything new in the house before skin problems (new carpet, etc)?

Seizures
How often?

How frequent?

How long?

Limping
Which leg?

How long?

Any known reaction to medications or vaccines?

Any other pre-existing problems (if new patient)?

Currently on any medications, and if so when was the last dose given?

Is your pet on heartworm prevention? If so, what kind?

If not when was the last preventative given?

Any additional information:

May we start diagnostic tests or X-rays? May we start treating the problem?

Is there a strict limit on the dollars to be spent?

Phone
Phone TypePhone Number
TO PROTECT THE HEALTH OF ALL OF OUR PATIENTS, IF YOUR PET HAS FLEAS OR TICKS WE WILL APPLY A PREVENTATIVE ON HIM OR HER AT AN ADDITIONAL CHARGE.
UNLESS EMERGENCY TREATMENT IS REQUIRED, WE INTEND TO DISCUSS WITH YOU ANY OTHER PROCEDURES AND/OR TREATMENTS AS WELL AS APPROXIMATE COSTS BEFORE PROCEEDING.
Owner/Agent Signature

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