Patient Name* Client* First Last Date* MM slash DD slash YYYY Drinking* Increased Decreased Normal Last drank* Appetite* Increased Decreased Normal Last ate* Urination* Increased Decreased Normal Last urinated* Defecation* Increased Decreased Normal Last bowel movement* Any Diarrhea?* Yes No Frequency Liquid Soft Increased frequency Any Vomiting?* Yes No Frequency Food Bile Other If "other", please describe Any Coughing?* Yes No Frequency/ Describe Any Sneezing?* Yes No Frequency Clear Mucus Is your cat on any monthly flea and/or heartworm preventatives?* Yes No If yes, brand AND date of last dose Is your cat on any regular medications?* Yes No Medicine #1 Frequency Dose Last given Medicine #2 Dose Frequency Last given Medicine #3 Dose Frequency Last given What is your cat's regular diet brand/feeding schedule?*Lifestyle* Indoor only Indoor/Outdoor Outdoor only Any other issues or specific concerns you would like addressed today?*Do you need any prescription refills or food today?*Special Requests* Nail Trim ($16) Ear Cleaning ($23) Other Please specify We ask that you please remain in your vehicle or on-site during the exam. One of our doctors or staff members will contact you by phone as soon as the exam is complete to discuss findings and any recommendations or necessary treatments and to obtain payment electronically (if paying by cash or check, please let us know in advance). Please read and initial:By initialing, I am authorizing Mid Atlantic Cat Hospital to examine my cat. I understand that I will be contacted with the exam findings and to discuss any recommended diagnostics or treatments that may be necessary.* Sedation authorization - Please read and initial ONE of the following:If a light sedative is necessary to help my cat's anxiety or stress in order to allow for a more complete exam or completion of diagnostics or treatments , I authorize the doctor to sedate my cat. This sedative may be either an oral medication or an injection given that helps to "take the edge off." It does not fully sedate the cat. I do not authorize any sedation of my cat. Please call if sedation is deemed necessary Signature of Owner/Agent*Primary Phone # to contact you at*We thank you for your understanding as we work to continue to provide you the exceptional care you have come to expect during this difficult time. Thank you for choosing us today and trusting us with your cat's care! We hope to resume normal operation and hours as soon as possible.CommentsThis field is for validation purposes and should be left unchanged.