Belle Mead Animal Hospital
872 Route 206 Hillsborough NJ 08844
Office 908.874.4447 Fax 908.874.4144
www.bmvet.com
Drop Off Exam Check-In Sheet
The purpose of this form is to let our doctors and staff be a better service in treating
you pet.
What is your pet being dropped off for?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are there any other problems or medications that we should be aware of?
___________________________________________________________________________________________________________________
When and what did your pet last eat?
___________________________________________________________________________________________________________________
Has there been any change in his/her diet recently?
Is your pet Indoor or Outdoor?
Is your pet:
Eating Normally?
Drinking Normally?
Coughing?
Sneezing?
Experiencing Diarrhea?
Vomiting?
Yes
Indoor __________________
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Does your pet have a normal energy level?
No
Outdoor ___________________
If not, for how long?_________________________
If not, for how long?_________________________
If so, for how long?__________________________
If so, for how long?__________________________
If so, for how long?__________________________
If so, Initial Vomiting ______________________
Frequency ___________________________
Last Occurrence ______________________
Yes
No
If not, for how long? __________________
Do we have your permission to sedate or anesthetize your pet if needed?
Yes
No
If your pet is a diabetic:
Did you give insulin today?
Yes
No
How much insulin? ___________________
When is the last time you changed the insulin dosage? ____________________________________________________
Capstar- Capstar is a flea treatment used to kill fleas on dogs and cats, which begins working within
30 minutes. ($10.29)
_____Please phone me for a discussion and estimate before completing diagnostics
Or
_____Please proceed with the diagnostics recommended by the doctor. Diagnostic testing is
done only after a complete physical examination by a doctor. The results of these diagnostic
tests may be necessary to identify and appropriately treat your pet.
Signature ____________________________________________________________________ Date___________________
Contact Number______________________________________________________________________________________