Vitamin & Mineral Supplements:
Please list any medical problems/Primary Complaint:
Current treatments or supplements:
Please list any previous medical problems:
Have you noticed:
[checkbox haveYouNoticedRabbit use_label_element "Weight Loss" "Weight Gain" "Masses or Lumps (indicate location below)" "Abnormal Urination" "Abnormal Stools" "Discharges (describe below)" "Difficult Breathing" "Cough/Gag" "Sneezing" "Nasal Discharge (describe below)" "Excessive Shedding" "Hair Loss" "Itching" "Skin Sores (indicate location below)" "Eye Discharge" "Lethargy" "Inactivity" "Pain (indicate location below)"]
Describe details from above or other changes:
To the best of my knowledge, the information provided above and on the patient history form is accurate and complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged.