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9818 Fry Rd Ste 180. Cypress, TX 77433
832-930-7717
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Home
COVID-19
About Us
Services
Schedule Appointment
Emergency Care
Refer a Friend
Testimonials
Forms
Hospitalization Form
Medical Boarding Form
New patient/New client Form
Emergency Exam Form
Medical Concern Form
Annual Exam Form
Tech Appointment Form
Medical Progress Exam Form
Anesthesia/Surgical Consent Form
Join Our Team
Contact Us
Medical Concern Form
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
Select All
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)
Select All
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
No
Is your pet on any medications?
This includes heartworm/flea prevention, over the counter and prescription
Yes
No
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
No
Unsure
If Yes, please specify
Does your pet spend time outside, even for walks or in the yard?
Yes
No
Does your pet come into contact with other dogs?
Please check all that apply
Boarding
Grooming
Dog Parks
Other
None of the above
Select All
Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?
Yes
No
Is your pet on any medications?
Yes
No
If Yes, please specify
Is your pet current on vaccines?
Yes
No
Unsure
If Yes, please specify which vaccine and expiration date
Microchip:
Yes
No
Unsure
*There is an additional fee for this
Nail Trim:
Yes
No
*There is an additional fee for this
Do you need heartworm or flea prevention:
Yes
No
*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
No
PAYMENT:
(Required)
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 $54, 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 ($54.00 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
No
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
No
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
Select All
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*
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.
Cancellation Policy:
(Required)
I understand that appointment cancellations less than 24 hours before appointment and/or no shows will incur a $30.00 cancellation fee.
Please type your initials.
(Required)
Date
MM slash DD slash YYYY
Signature
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Name
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