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WE TAKE BETTER CARE OF YOUR BEST FRIEND!
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THE HOSPITAL
About Us
Hospital hours
Location & Map
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General Information
Current News And Events
Newsletter
SERVICES
Veterinary Services
Boarding Services
Grooming Services
Referral Services
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THE STAFF
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RESOURCES
Lost & Found
A Guide to a Lifetime of Good Health
Forms
Online Pets Guide
Employment
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Traveling With Your Pet
Client's Name:
Pet's Name:
Today's Date:
Date symptoms started:
Appetite:
Eating Normally
Not Eating
Gastrointestinal/Digestive:
Normal Stools
Loose Stools
Hard Stools
Blood is present in Stool
He/She Straining
He/She Scooting
Vomiting
Urinations:
Urinating normally
Straining
Blood is present in urine
Urinating in the house
Not urinating at all
"Leaking" urine
Respiratory :
Breathing Normaly
Gagging
Coughing
Having Breathing difficulties
Activity:
Acting Normal
Hyper- active
Lethargic
Ears:
Shaking head
Scratcing ears
Swollen
Weight:
Gained weight
Loose weight
None of the above
Eyes:
Red/Inflammed
Squinting
Right Eye
Left Eye
Other symptoms:
My pet has:
Had a seizure
Is your pet limping?
Yes
No
If yes, which leg?
Front Right
Front Left
Back Right
Back Left
Is your dog on heartworm preventative?
Yes
No
When and where did your pet have their last vaccines?
Please give us any information about you pet and his/her sympotms that may assist us:
I authorize the Doctor to perform X-ray if needed (estimated cost range $102.00-$163.00) Price may vary with pet size and number of views needed
Yes
No
I authorize the doctor to spend up to $
(basic diagnostic blood test and urinalysis cost $177.00)
in diagnostic prior to contacting me.
Phone # where you can reached
Alternative phone #
if we cannot reach you, do you want us to procced with treatment?
Yes
No
I agree that I am the owner of this pet and allow the doctor(s) at Southlake Crossing Animal Clinic to treat my pet. Furthermore, I agree to pay for all charges that are incurred and I understand full payment is required at discharge.
Yes
No
Date
Submit
What is
AAHA
?
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