Echocardiogram Drop Off Admission Form

If you have called and scheduled an Echocardiogram appointment for your pet, please take a moment to answer the following questions and submit your answers before you bring your pet for admission. The check in process takes between 10 and 15 minutes. To save some time at check-in, please answer as many questions as you can, in as much detail as you can. If you have any questions while completing this form, we will be happy to answer them when you arrive with your pet. Check in time for admission is between 7:45am and 10:00am, we encourage you to bring your pet for check-in as early as possible before 10:00 am. Our phones are on between 8:00am and 5:00pm, mon-fri and 8:00am to noon on sat. Please call on us at 504-866-6316 if you have any questions.

Your First & Last Name*
Please provide your first and last name
Your Email Address*
Enter Email
Best Phone Number to reach you*
Best Phone Number to reach you
Pet's Name*
Date of Drop Off Echocardiogram Appointment*
The date you have scheduled to drop off your pet for an echocardiogram. *An appointment must be scheduled prior to submitting this form. Please call 504-866-6316 to schedule an appointment BEFORE submitting this form.
Date Format: MM slash DD slash YYYY
Name and Phone# of Primary Person to Call on Date of Drop Off:*
Please give us the name and phone number of the person the Doctor should call after examining your pet (It is imperative that we be able to reach this person):
Name & Phone# of Secondary Person to Call on Date of Drop Off:*
Please give us the name and phone number of another person the Doctor can call and speak to about your pet, should we not be able to reach the Primary Person above.
Is your pet experiencing any of the following?*
Please check ALL that apply
- Coughing
- Difficulty Breathing
- Fainting
- Seizures
- Diarrhea
- Loose Stool
- Scooting
- Vomiting
- Sneezing
- Scratching
- Shaking Head
- Sores or Scabs
- Increased Urination
- Decreased Urination
- Straining to Urinate or Defectate
- Increased Thirst
- Decreased Thirst
- Increased Appetite
- Decreased Appetite
- Limping
- Difficulty Rising
- Weight Gain
- Weight Loss
- Lethargy
- None of the Above
If you answered Yes to Coughing, how long has patient been coughing and how often?
If you answered Yes to Difficulty Breathing, please indicate below - is breathing labored, faster, slower etc? And how long do episodes last?
*If you have a video of your pet while experiencing difficult breathing, please attach it below.
If your Doctor has requested that you monitor and record your pets Resting Respiratory Rate, please indicate recent results below:*
- RRR Under 30
- RRR Over 30
- Not asked by Doctor to Monitor RRR
Any additional services you would like performed:*
Please check all that apply
- Nail Trim
- Anal Gland Expression
- Clean Ears
- None
- Other (please indicate below)
Additional service(s) requested, not listed above:
Please list below all of Medications and/or Supplements your pet is currently taking:*
Please list names of drugs, dosing instructions & when he/she last received their last dose. If not on medication, please type "None"
Do you need a refill of any medication(s) when you pick up your pet?
Please list which medication or supplements we can refill for you:
Consent for Treatment
Authorization
Authorization: By completing the above information and selecting this authorization, I hereby certify that I am the owner, or duly authorized agent of the owner of the animal described above and that I do hereby give Maple Small Animal Clinic, its veterinarians, agents and/or representatives full and complete authority to perform the treatments requested. I understand that if an examination is performed a doctor will contact me to discuss recommended diagnostic tests and/or treatments if recommended. I accept full responsibility for all tests and treatments that I requested above or verbally authorize during my conversation with the doctor. I understand that payment is due when my pet is discharged. I further understand that if evidence of fleas is found on my pet during examination, a dose of flea prevention will be administered at my expense.
Photos, Video or Records you would like Doctor to see
Drop files here or

Accepted file types: jpg, gif, png, pdf, mov.
If you have photographs, video, or records you would like to share with the doctor, please upload them here.

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

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Echocardiogram Drop Off Admission Form