VANCOUVER EMERGENCY INTERNAL MEDICINE CLIENT 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 firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
SECONDARY CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

REFERRING HOSPITAL INFORMATION

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

PATIENT INFORMATION

{ binding firstError.message }
{ binding firstError.message }
GENDER {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
HOW DID YOU ACQUIRE YOUR PET? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please list other pets in the home.

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please list when and where your pet has travelled to.

{ binding firstError.message }

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 }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please indicate any known adverse reactions/allergies to vaccines, oral medications, anesthetics and/or topical drugs or shampoos.

{ binding firstError.message }

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

{ binding firstError.message }

MEDICAL HISTORY

HAS YOUR PET RECENTLY HAD AN XRAY? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ 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 firstError.message }
{ binding firstError.message }
CHANGE IN URINATION? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
CHANGE IN APPETITE? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
VOMITING? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
DIARRHEA  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
CHANGE IN BEHAVIOUR? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

RELEVANT DOCUMENTS

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

{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }

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

{ 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 firstError.message }

VANCOUVER EMERGENCY INTERNAL MEDICINE CLIENT 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 }
SECONDARY CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Secondary Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Secondary Email {{ 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 }
PRIMARY CARE HOSPITAL {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
REFERRING VETERINARIAN (IF DIFFERENT THAN ABOVE) {{ 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 }
Please list all veterinary hospitals that your pet has visited: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ 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 }
PET'S COUNTRY OF ORIGIN {{ 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 AND WHERE? {{ 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. PLEASE DESCRIBE {{ 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. PLEASE DESCRIBE {{ 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 }
IF YES. PLEASE DESCRIBE {{ 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 }
IF YES. PLEASE DESCRIBE {{ 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. PLEASE DESCRIBE {{ 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 }
Do you have Pet Insurance? If so, who is your pet insured with? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }
The email has been sent.

Your progress has been saved.

{ binding firstError.message }

VANCOUVER EMERGENCY INTERNAL MEDICINE CLIENT 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 }
SECONDARY CLIENT NAME {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Secondary Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Secondary Email {{ 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 }
PRIMARY CARE HOSPITAL {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
REFERRING VETERINARIAN (IF DIFFERENT THAN ABOVE) {{ 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 }
Please list all veterinary hospitals that your pet has visited: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ 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 }
PET'S COUNTRY OF ORIGIN {{ 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 AND WHERE? {{ 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. PLEASE DESCRIBE {{ 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. PLEASE DESCRIBE {{ 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 }
IF YES. PLEASE DESCRIBE {{ 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 }
IF YES. PLEASE DESCRIBE {{ 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. PLEASE DESCRIBE {{ 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 }
Do you have Pet Insurance? If so, who is your pet insured with? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ 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 }