Medical History Emergency Form

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Medical History: Emergencies

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Contact Information
Your name

First NameLast Name
Your email
Optional: If you enter in your email, we can send you a copy of this form to you.
Phone number where you can be reached today
(XXX) XXX-XXXX
Your pet's name
What is your primary concern (reason for visit) today?*
describe the reason for your visit
Is the problem the result of a trauma?*
e.g. hit by car, fall, N/A, etc.
When was your pet last normal?*
Is your pet currently experiencing any of the following symptoms?
Difficulty breathing*

YesNo
Collapse*

YesNo
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures*

YesNo
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
Coughing*

YesNo
When did it start?
How often does it occur?

Medical History: Emergencies