VANCOUVER EMERGENCY CLIENT INTERNAL MEDICINE FORM

Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CLIENT INFORMATION

CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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REFERRING HOSPITAL INFORMATION

PRIMARY VETERINARIAN NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PATIENT INFORMATION

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GENDER {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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HOW DID YOU ACQUIRE YOUR PET? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please list other pets in the home.

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Please list when and where your pet has travelled to.

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If yes, when did you remove the tick?

DOES YOUR PET HAVE ANY KNOWN FOOD ALLERGIES OR INTOLERANCES? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please indicate any known adverse reactions/allergies to vaccines, oral medications, anesthetics and/or topical drugs or shampoos.

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Please list all medications including topical medication, flea prevention, and herbal vitamins/supplements. List name, dose, how often and last given.

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MEDICAL HISTORY

HAS YOUR PET RECENTLY HAD AN XRAY? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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HAVE YOU NOTICED ANY OF THE FOLLOWING IN YOUR PET?
CHANGE IN WATER INTAKE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CHANGE IN URINATION? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CHANGE IN APPETITE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
VOMITING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DIARRHEA  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CHANGE IN BEHAVIOUR? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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RELEVANT DOCUMENTS

If you have any additional photos or documents, please upload here.

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Max File Size: 10mb Max Number of files: 10

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I consent to the use and storage of my information in accordance with the terms and conditions detailed in the VCA Canada Privacy Statement, a copy of which is available at vcacanada.com/privacy-policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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VANCOUVER EMERGENCY CLIENT INTERNAL MEDICINE FORM

Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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CLIENT INFORMATION

CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

REFERRING HOSPITAL INFORMATION

PRIMARY VETERINARIAN NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
REFERRING HOSPITAL {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

PATIENT INFORMATION

PET NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PET DATE OF BIRTH {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
GENDER {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
SPECIES/BREED {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HOW DID YOU ACQUIRE YOUR PET? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DO YOU HAVE ANY OTHER PETS AT HOME? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
WHAT FOOD(s) DOES YOUR PET EAT? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
HAS YOUR PET TRAVELLED OUTSIDE OF VANCOUVER? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HAVE YOU REMOVED ANY TICKS FROM YOUR PET {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DOES YOUR PET HAVE ANY KNOWN FOOD ALLERGIES OR INTOLERANCES? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PLEASE LIST KNOWN ALLERGIES OR ALLERGEN TESTING DONE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DRUG REACTIONS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CURRENT MEDICATIONS & SUPPLEMENTS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

MEDICAL HISTORY

HAS YOUR PET RECENTLY HAD AN XRAY? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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IF YES, HOW LONG AGO? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HAVE YOU NOTICED ANY OF THE FOLLOWING IN YOUR PET?
CHANGE IN WATER INTAKE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED AN INCREASE OR DECREASE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN URINATION? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED ANY STRAINING OR BLOOD?  WHAT IS THE FREQUENCY THAT THIS IS HAPPENING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN APPETITE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
VOMITING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DIARRHEA  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED ANY BLOOD OR MUCUS?  WHAT IS THE FREQUENCY THAT THIS IS HAPPENING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN BEHAVIOUR? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES, PLEASE DESCRIBE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YOUR PET IS HERE FOR SEIZURES, PLEASE LIST WHEN THEY HAPPENED AND THE DURATION OF EACH EPISODE: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
PLEASE LIST ANY CHRONIC OR PREVIOUS MEDICAL PROBLEMS, OR ANY OTHER CONCERNING SYMPTOMS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

RELEVANT DOCUMENTS

Upload Files Here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
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I consent to the use and storage of my information in accordance with the terms and conditions detailed in the VCA Canada Privacy Statement, a copy of which is available at vcacanada.com/privacy-policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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The email has been sent.

Your progress has been saved.

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VANCOUVER EMERGENCY CLIENT INTERNAL MEDICINE FORM

Date: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

CLIENT INFORMATION

CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

REFERRING HOSPITAL INFORMATION

PRIMARY VETERINARIAN NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
REFERRING HOSPITAL {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

PATIENT INFORMATION

PET NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PET DATE OF BIRTH {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
GENDER {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
SPECIES/BREED {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HOW DID YOU ACQUIRE YOUR PET? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DO YOU HAVE ANY OTHER PETS AT HOME? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
WHAT FOOD(s) DOES YOUR PET EAT? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
HAS YOUR PET TRAVELLED OUTSIDE OF VANCOUVER? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HAVE YOU REMOVED ANY TICKS FROM YOUR PET {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DOES YOUR PET HAVE ANY KNOWN FOOD ALLERGIES OR INTOLERANCES? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PLEASE LIST KNOWN ALLERGIES OR ALLERGEN TESTING DONE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DRUG REACTIONS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
CURRENT MEDICATIONS & SUPPLEMENTS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

MEDICAL HISTORY

HAS YOUR PET RECENTLY HAD AN XRAY? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES, HOW LONG AGO? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
HAVE YOU NOTICED ANY OF THE FOLLOWING IN YOUR PET?
CHANGE IN WATER INTAKE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED AN INCREASE OR DECREASE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN URINATION? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED ANY STRAINING OR BLOOD?  WHAT IS THE FREQUENCY THAT THIS IS HAPPENING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN APPETITE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
VOMITING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DIARRHEA  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES HAVE YOU NOTICED ANY BLOOD OR MUCUS?  WHAT IS THE FREQUENCY THAT THIS IS HAPPENING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
CHANGE IN BEHAVIOUR? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YES, PLEASE DESCRIBE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
IF YOUR PET IS HERE FOR SEIZURES, PLEASE LIST WHEN THEY HAPPENED AND THE DURATION OF EACH EPISODE: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
PLEASE LIST ANY CHRONIC OR PREVIOUS MEDICAL PROBLEMS, OR ANY OTHER CONCERNING SYMPTOMS: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

RELEVANT DOCUMENTS

Upload Files Here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
{ binding firstError.message }
I consent to the use and storage of my information in accordance with the terms and conditions detailed in the VCA Canada Privacy Statement, a copy of which is available at vcacanada.com/privacy-policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }