Just Cats Veterinary Services

1015 Evergreen Circle
The Woodlands, TX 77380

(281)367-2287

www.justcatsvets.com

Patient History Form for Exams

***At this time we are only seeing curbside and drop off appointments***

Please fill out the name, phone number, and email address of the person we will be contacting during the appointment time. It is imperative that you be available to discuss and approve/decline treatments while your cat is in our care.

The doctor will contact you during or after the exam with the exam findings and recommendations. Your technician will then email you the treatment plan to the email address you provide. You must reply via email with approval/declination of services prior to any services being rendered.

The patient history form is required for all office visits.

Patient History

Cell Phone Number (required)

E-Mail Address

Make, Model, and Color of Vehicle you will be arriving in (required)

In the event of an emergency requiring resuscitation (anaphylactic or anesthetic reaction, cardiac arrest, etc) (required)

I authorize CPR and/or associated medications/procedures to resuscitate my pet, and will be responsible for any additional charges
Please do not resuscitate my pet

Patient Name (required)

Summary of your concerns with your kitty: (required)

Current Medications - Please include ALL medications your cat is currently taking or has recently taken

Please list as medication name, dosage, directions for use, and when it was last given (Ex: Cerenia 16mg - 1/2 tab every 48 hours - Last Given: 1/2/18 at 3pm) (required)

Feeding Information

Canned Food Brand (required)

Flavor (required)

Amount (required)

Dry Food Brand (required)

Flavor (required)

Amount (required)

Please answer the questions below to help us better help your kitty

Has your cat vomited or had hairballs in the last 30 days? (required)

Yes
No

Has your cat spent any time outdoors in the last year? (required)

Yes
No

Have you noticed any changes in the following areas?

Appetite (required)

Yes
No

Water Consumption (required)

Yes
No

Urination (required)

Yes
No

Defecation (required)

Yes
No

Activity Level (required)

Yes
No

Reluctance to jump or run (required)

Yes
No

Limping (required)

Yes
No

Itching/Hair Loss (required)

Yes
No

Nasal/Ocular Discharge (required)

Yes
No

Sneezing (required)

Yes
No

Coughing (required)

Yes
No

Behavior (required)

Yes
No

History of fight wounds (required)

Yes
No

Curbside/Drop Off Consent
I am the owner or agent of the cat named above and have the authority to execute this consent. I understand that during the performance of procedure(s)/operation(s), unforeseen conditions may be revealed that necessitates an extension of the foregoing procedure(s)/operation(s) or different procedure(s)/operation(s) than those provided in the treatment plan. I hereby consent to authorize the performance of such procedure(s)/operation(s) as are necessary and desirable in exercise of the veterinarian's judgement. I have been advised as to the nature of the procedure(s)/ operation(s) and the risks involved. I realize that the results cannot be guaranteed. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. To prevent the spread of infectious disease, any cat with fleas will be treated with an oral and/or topical medication upon admission to the hospital. The price of the treatment will be added to your invoice. I have read and understand this authorization and consent. By submitting this form I hereby consent and authorize the performance of the procedures that I have approved in the treatment plan. I agree to pay all charges incurred when my cat is released from the hospital.

Please initial below if you have read the above and authorize the performance of the estimated treatments/procedures (required)

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1015 Evergreen Circle
The Woodlands, TX 77380

P: (281) 367-2287
F: (281) 367-0700
vets@justcatsvets.com

Hours of Operation:
Monday-Friday: 7am-6pm
Saturdays: 8am-12pm
Sundays: Closed