ANIMAL EMERGENCY AND REFERRAL CENTER
3984 South U.S. Highway 1 · Fort Pierce, FL 34982 Phone (772) 466-3441 · Fax (772) 466-0206
www.animalemergency.net

CURRENT MEDICATIONS

DATE*

CLIENT NAME*

CLIENT EMAIL*

PATIENT NAME*

CURRENT DIET*

PLEASE WRITE THE DAY, DATE, AND TIME YOUR PET LAST ATE ANY FOOD/TREATS*

DOES YOUR PET HAVE ANY ADVERSE (BAD) REACTIONS TO ANY MEDICATIONS?

NAMES/DATES OF ALL VACCINATIONS (within 1 year)*

PHARMACY NAME*

PHARMACY PHONE NUMBER*

List all prescription or over-the-counter medications and/or nutritional supplements you are currently giving to your pet (including heartworm prevention and flea control). This is vital to the proper management of your pet’s medical condition. Even if you are here for a recheck visit, please take a moment to provide the doctors with this important information so that we are all “on the same page”.

NAME OF MEDICATION
STRENGTH
mg/tablet or capsule; mg/mlor cc if liquid
DOSAGE
(How much do you give and how many times daily or every other day, etc.)
REFILL NEEDED? Y/N
YN
YN
YN
YN
YN
YN
YN
YN
YN