Medical Concern Form - True Companion

Name(Required)

First Last

Phone(Required)

Email(Required)

Pet's Name(Required)

Who should we contact to make medical decisions today?

Owner (Named Above)

Someone Else (Named Below)

If you have any questions, please contact our team members prior to your arrival for assistance.(Required)

I have read and understand.

Reason for visit: (check all that apply)

Illness

Injury

Other

What symptoms has your pet been experiencing?

Are there any concerns for the following: (check all that apply)

Increase in appetite

Decrease in appetite

Increase in drinking

Decrease in drinking

Weight Loss

Weight Gain

Itching/Scratching

Shaking Head

Bad Breath

Vomiting

Diarrhea

Urination Issues

Excessive Sleeping

Scooting

Difficulty Rising

Skin Masses (explain below)

Car Sickness

Behavioral Problem

Other (explain below)

When did the problem start?

Have the symptoms worsened, improved, or stayed the same since you first noticed them?

No change

Worsened

Improved

Has your pet experienced this problem in the past?

Yes

Is your pet on any medications?

This includes heartworm/flea prevention, over the counter and prescription

Yes

What brand of food do you feed your pet?

How much do you feed?

Free fed (food is offered always/whenever hungry)

Measured amount (specify how much and how often below)

Specified Amount

Have there been any changes in appetite?

Increased

Decreased

No change

If there has, for how long? Please elaborate.

Any increase or decrease in water consumption?

Increased

Decreased

No change

Any change in bowel movements?

Yes

Unsure

If Yes, please specify

Does your pet spend time outside, even for walks or in the yard?

Yes

Does your pet come into contact with other dogs?

Please check all that apply

Boarding

Grooming

Dog Parks

Other

None of the above

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?

Yes

Is your pet on any medications?

Yes

If Yes, please specify

Is your pet current on vaccines?

Yes

Unsure

If Yes, please specify which vaccine and expiration date

Microchip:

Yes

Unsure

*There is an additional fee for this

Nail Trim:

Yes

*There is an additional fee for this

Do you need heartworm or flea prevention:

Yes

*There is an additional fee for this

If Yes, please specify

CPR PERMISSION(Required)

I understand True Companion Veterinary Care, PLLC (TCVC) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of TCVC, PLLC will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400. I understand that there is no guarantee of successful resuscitation.

Yes, please perform CPR on my pet.

No, do not perform CPR on my pet.

Was your pet last seen by a veterinarian at True Companion Veterinary Care?

Yes

PAYMENT:(Required)

Photo ID required for all credit card, debit card, Care Credit and Scratchpay transactions. The photo ID must match the name on the card. All credit card, debit card, Care Credit and Scratchpay holders must be physically present to run the card and sign the transaction in person.

Payment in full is required at the end of your visit today. Once your pet’s exam is completed, we will contact you to go over the exam findings and recommendations. We accept Visa, Mastercard, American Express, Discover, CareCredit and Scratchpay for payment. Should you opt for CareCredit or Scratchpay as your form of payment, we ask that you apply prior to your visit to streamline your appointment. We do not accept checks and strongly discourage the use of cash due to the global pandemic.

I understand.

APPOINTMENTS:(Required)

To ensure your appointment is as timely as possible, we strongly recommend that the pet parent (responsible party) attend or bring the pet to the exam with the Veterinarian. A cancelation fee deposit of $65, will be collected when scheduling your pet’s next exam if you cancel, reschedule or miss the appointment in less than 24 hours. When appointments are not kept or canceled in a timely fashion, it prevents us from scheduling patients that need medical attention. The deposit will be applied towards your pet's exam fees at the time of discharge. If you're unable to cancel the appointment with a 24-hour notice, the deposit will be forfeited. We offer appointments 6 days a week, including 9am – 3:30pm on Saturdays - please take advantage of our extended hours to make sure you are available for your pet's exam.

I understand.

MEDICAL EXAMS:(Required)

If you are requesting that we vaccinate your pet, please be advised by state law, we can only vaccinate pets healthy enough to receive a vaccine. To determine if they are healthy, we require a physical exam performed by our Veterinarian to ensure we are only vaccinating healthy pets. If we administer vaccines you will be charged for a Exam ($65.00 plus vaccine costs) annually as well as any needed tests. If one of our Doctors has examined your pet over 30 days ago we will require another exam, to ensure your pet is healthy enough to receive a vaccine. Other fees will apply for pets that are sick or Injured as well as for Work-In Appointments or Emergencies.

I understand.

Social Media/Photo Permission

Do we have your permission to post photos of your pet online? Your pets' picture or video may be taken while they are with us and used for True Companion Veterinary Care advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Instagram, etc.). Please indicate if you authorize for their pictures/videos to be posted or used. * If you do not authorize for your pet’s picture to be included in our marketing materials/venues, we may still use a picture of your pet in our patient records for our internal identification only*

Yes

Once the doctor has completed your pet’s exam, we will contact you to go over the recommended treatment plan.(Required)

I understand that financial responsibilities for services are rendered at the time of discharge.

I have read and understand.

I give True Companion Veterinary Care authorization to treat as discussed above.(Required)

I have read and agree.

If Curbside care is elected:(Required)

If Curbside care is elected: During the duration of the exam, your pet will be in the care of one of our team members. A team member will collect your pet from outside the building and support them through the exam, any services required, and then bring them back to your vehicle, when your pet is ready to go home. We strongly recommend you head home and a veterinarian or nurse will call you to discuss your pet’s exam and discuss recommended treatments, preventative measures and give an estimated discharge time.

I have read and understand.

Please type your initials.(Required)

Date

MM slash DD slash YYYY

Please text photos of your pet's records to 832-930-7717 and/or email records to hospital@truecompanionvetcare.com so that your veterinarian knows which vaccines or treatments have already been started. We need records before your appointment.

Have you or anyone that you have had close contact with tested positive for COVID-19 in the past 14 days?

Yes

Have you or anyone in your house experienced the following symptoms in the past 14 days?

Cough

Shortness of breath

Fever

Sore throat

Chills

Muscle pain

Headache

New loss of taste or smell

Who experienced these symptoms?

Self

Someone else in the house

No symptoms

If you are ill or have been exposed to someone who is ill, we request that a family member or friend bring your pet to their appointment*

I have read and understand.

Cancellation Policy:(Required)

I understand that appointment cancellations less than 24 hours before appointment and/or no shows will incur a $65.00 cancellation fee.

Please type your initials.(Required)

Date

MM slash DD slash YYYY

Signature

This field is for validation purposes and should be left unchanged.