Ultrasound/CT Intake Form

Schedule Your Visit: 413-614-0039

Then complete the intake form below:

Ultrasound/CT Intake Form

Owner Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Patient Name:(Required)

Age:(Required)

Breed:(Required)

Gender:(Required)

What imaging is your pet having done today?(Required)

How is your pet feeling today? Are they showing any concerning signs or symptoms?(Required)

When was the last time your pet ate? What and how much did they eat?(Required)

Does your pet have any other known medical problems? If so, please list them below.(Required)

Has your pet ever had surgery, apart from their spay or neuter? If so, what kind?(Required)

To your knowledge, has your pet generally handled sedation and anesthesia well in the past? If not, what concerns were there?(Required)

Does your pet have any known allergies to foods or medications? If so, what are they?(Required)

What veterinary practices or hospitals has your pet been to (names and contact information please)?(Required)

What medications is your pet taking? Please list the name of the medication, tablet size or liquid concentration (ex: 20 mg tablets), dose and frequency of administration, and last time administered.(Required)

Is your pet taking any supplements, herbs, or vitamins? If so, please list the name, brand, and dose.(Required)

Has your pet ever taken pre-visit medications to reduce their anxiety at the vet? If so, what medication(s) and dose(s)?(Required)

What brand of food is your pet eating, and how much do they eat per day? Also, please describe any treats they receive on a regular basis.(Required)

Is there anything else we should know about your pet prior to your appointment?(Required)