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SALEM VETERINARY EMERGENCY CLINIC

Hours for Patient Admission:

Mon - Thurs: 8am - 10pm

Fri: all day starting at 8am

Sat: 24 hours

Sun: all day until 10pm

Holidays: 24 Hours

3215 Market St NE

Salem, Oregon 97301

PHONE: 503-588-8082

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Dog Shaking Hand

PATIENT MEDICAL HISTORY

If you would like to have a pet seen at our hospital today, please fill out this medical history questionnaire and call us as soon as you arrive.

Questions with a star * beside them are required.

I understand that the initial exam fee is $150 on Weekdays, $200 after midnight on Fridays and Saturdays, and $200 on Holidays and Holiday Weekends.I understand that the exam fee is an initial fee and that I will be given an estimate for further treatments, diagnostics, and medications.

Owner Name(s): First and Last Name

Pet's Name:

Pet's Primary Care Veterinary Clinic:

Is your pet current on vaccinations?

Pet's Current Diet or Brand of Food:

Please describe the reason for your pet's emergency or urgent care visit today.

Check any symptoms your pet is experiencing or has experienced recently: * Required

No Symptoms Currently

Abnormal Behavior (describe above)

Bleeding

Bloody Stool

Bloody Urine

Breathing Difficulty / Gasping

Constipation

Coughing

Decreased Appetite

Diarrhea

Difficulty Walking / Inability to Walk

Discharge (describe above)

Drooling

Excessive Thirst

Fever

Frequent Urination

Incontinence (leaking urine, unable to control bowels, etc)

Itching / Scratching

Lethargy / Depression

Limping / Not Weight Bearing

Not Eating / Not Drinking

Pain

Seizures / Involuntary Tremors

Shaking

Sneezing / Congestion

Straining or Inability to Urinate

Swelling / Inflammation

Unproductive Vomiting / Dry Heaving

Vomiting

Weight Loss (unintentional or unexplained)

*In Need of End of Life Care*

When did these symptoms start? Or when did the incident happen?

Any previous medical issues or diagnosed conditions?

Any recent changes in your pet's diet or environment?

Has your pet had reactions to vaccines or medications? Any known allergies or food sensitivities?

Is your pet currently taking medications (including supplements, vitamins, flea products, etc.)? Include dosage, how often medication is given, or last time dose was given.

My pet is transferring from another veterinary hospital:

I am parked in:

Color/Make/Model of your Vehicle:

I understand this is an emergency hospital. Patients must be seen in order of medical severity. Wait times may be several hours. If you're concerned, ask if we're able to assess your pet upon arrival.*

Salem Veterinary Emergency Clinic requests permission to photograph your pet and share information about them for purposes of education, research and socal media, both for internal and external use. * Required

Yes, I authorize the use of my pet's first name, photograph, and clinical information (including medical condition, treatments, and prognosis) by Salem Veterinary Emergency Clinic. Under no circumstances will my name, personal information, or financial information be shared with anyone unauthorized.

No, I do not authorize

Please give me more information

Doctors in our clinic may use Scribble Vet to audio record exam notes. Do we have your permission to take an audio recording of your pet's exam session with the doctor? * Required

Yes, I authorize you to record my pet's exam session using audio recording

No, I do not authorize

Please give me more information

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