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Oncology New Patient Form

Please complete the form below prior to your appointment. If you have any questions please email us at info@metro-vet.com.

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Patient Name*

Owner Name*

First Last

Household and Medical History

How long have you owned your pet?*

Where was your pet obtained?*

Sex*

Male

Female

Neutered/Spayed?*

Yes

No

If female not spayed, when was her last heat?

MM slash DD slash YYYY

Any known litters?*

Yes

No

Date

MM slash DD slash YYYY

Vaccination/Health History

Vaccination and Testing Details*

(Please include dates of last vaccination or check if up to date)

In general, how would you characterize your pet’s health prior to the current health issue?*

Diet/Appetite

What is your pet’s average weight?*

Any recent weight changes?*

Yes

No

If yes, describe

What is your pet’s normal diet?*

Has your pet’s appetite changed recently?*

Yes

No

If yes, please explain

Is your pet drinking more than usual?*

Yes

No

If yes, how much and for how long?

Medications

Is your pet currently taking any medications?*

Yes

No

Please list all medications, doses, and supplements

Has your pet ever had a reaction to any medications?*

Yes

No

If yes, describe

Has your pet ever had reactions to anything else (including foods)?*

Changes in Your Pet

Has your pet had any diarrhea or abnormal stools recently?*

Yes

No

Please describe stool appearance, frequency, duration, and treatment if any

Has your pet vomited recently?*

Yes

No

Please describe appearance, frequency, duration, and treatment if any

Has your pet been coughing recently?*

Yes

No

Describe cough

Has your pet been sneezing recently?*

Yes

No

Describe frequency, nasal discharge presence, and color

Activity Level

Has your pet been lethargic?*

Yes

No

If yes, how long?

Does your pet have difficulty during normal exercise?*

Yes

No

If yes, describe

Referring Veterinarian

What was the main concern that brought you to your regular veterinarian?*

Did your pet show any additional symptoms?*

Is there a mass or tumor present? If so, where on your pet’s body?*

What was your pet diagnosed with?*

What method was used to confirm diagnosis? (Aspirates, biopsies, etc.)*

Was blood work performed recently?*

Yes

No

Were X-rays performed recently?*

Yes

No

Was an ultrasound, CT scan, or MRI performed recently?*

Yes

No

I am the owner of the above pet, or am acting as an agent for the owner. I certify that all of the above information is correct to the best of my knowledge.

Date

MM slash DD slash YYYY

Signature*

In An Emergency

Phone MVA: 610-666-1050
Phone Hickory: 610-839-8538
Phone MVUCS: 610-616-8827

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