I am in this vehicle *

(Please list the model and color.)

Best phone number for today's appointment *

(The veterinarian and technician will use this number to communicate with you through the appointment.)

I consent to receive SMS text messages from Cottage Pet Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Email *

Patient's Name *

Patient's Species *

Canine/Dog
Feline/Cat

Owner's Name *

First

Last

Have you booked your appointment yet? *

Yes
No

If you have not booked an appointment yet, please do not fill out this form. Call us at 714-535-6714 to book your pet’s visit or use the form on our website.

Appointment Date/Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Patient's Energy Level

Normal
Increased
Decreased

List ALL medications your pet is currently taking. Please include dosage, frequency, and any flea/tick/heartworm or over the counter (including CBD) products:

Do you need refills of any of these medications?

Yes
No

If you need a medication refill, please list which medications:

If you do not need a refill, please put N/A.

Please list what diet / food your pet currently eats (include brand & feeding schedule) and all treats and how often given:

Do you need refills on any prescription pet food?

Yes
No

If you need a prescription pet food refill, please let us know which kind:

Patient's Appetite

Normal
Increased
Decreased

Drinking / Water Intake

Normal
Increased
Decreased

Is the patient coughing?

Yes
No

If 'Yes', for how long?

Is the patient sneezing?

Yes
No

Is the patient vomiting?

Yes
No

If 'Yes', for how long?

NEW CLIENTS/PETS: Does your pet have any previous diagnoses?

Yes
No

If 'Yes', please explain:

Have you or your pet traveled out the area?

Yes
No

If 'Yes', where?

Is your pet regularly taken for grooming?

Yes
No

Is your pet regularly taken for boarding?

Yes
No

Does your pet go to dog parks?

Yes
No

Is your cat kept strictly indoors, or is he/she an indoor/outdoor cat?

Indoor Only
Indoor/Outdoor

Does your pet have any lumps, bumps, or masses? If yes, please describe where on the pet's body they are located:

My signature authorizes that I will be giving VERBAL CONSENT via telephone while curbside, based on an accurate explanation of the treatment plan and charges provided to me by the veterinarian or veterinary technician who speaks with me during my pet's appointment. *

Please upload any necessary medical records:

Click or drag files to this area to upload. You can upload up to 5 files.

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Curbside Drop-Off Form

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