New PatientPet InformationPet’s Name(Required)Date(Required) MM slash DD slash YYYY Species(Required) Dog Cat OtherPlease Specify(Required)Breed(Required)Color(s)(Required)Sex(Required) Male/Intact Male/Neutered Female/Intact Female/SpayedIs your pet microchipped?(Required) Yes No Please scan for Microchip Number I would like to discuss microchipping my petRecord microchip (Staff use)Symptoms or ProblemsPlease check any symptoms or problems you have noticed regarding your pet.(Required) Behavioral problem(s) Bleeding gums/mouth Breathing changes Constipation Decrease activity Diarrhea Eye problems Gagging Increased thirst Lack of appetite Limping Lump/bump Scooting Shaking head Scratching/itchy Sneezing Urination changes Vomiting Weakness/lethargy Weight gain/loss OtherPlease Specify(Required)Treatment and Financial AuthorizationDogs: NNVM requires that all dogs over one year of age have a heartworm blood screen performed prior to dispensing/prescribing any heartworm prevention. This test is required annually thereafter for the purchase/ prescribing of prevention. Yes, I would like the heartworm blood screen and accept the additional cost of $69.55 No, I decline the blood screen at this time and understand I will not be able to purchase or get a prescription from NNVH for heartworm preventionCats: NNVM recommend that all cats and kittens be tested for Feline Leukemia Virus and Feline Immunodeficiency Virus. Identifying these underlying conditions could aid in the treatment of your cat. Yes, I would like the Feline Combo test and accept the additional cost of $74.98 No, I decline the Feline Combo test.Owner/Authorized Agent SignatureDate MM slash DD slash YYYY Δ
