URINALYSIS FORM

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Client Name *

First

Last

E-mail *

What is the best number to reach you at today? *

Would you prefer we provide test results by email or phone? *

Email
Phone
No Preference

Patient Name *

Patient Species *

Did the doctor request a UA due to blood results? *

Is your pet leaking urine while sleeping/resting? *

Is he/she urinating more than normal? *

Is he/she drinking more than normal? *

Have you noticed any blood or discoloration in the urine?

Is he/she straining to urinate but can't? *

How long has the problem been going on?

What type of food do you feed?

Have you changed food brand/type recently?

Has he/she been on any medications? If yes, please list:

Is this a recheck to make sure the problem has been eradicated?

How was the sample collected? *

Free Catch
Off Floor
Other

If other, please explain: *

When was the sample collected?

Name

We are currently not accepting new clients.
Online appointment requests are only for existing patients in need of a routine visit. If your pet is sick or needs an urgent visit, please call or text the office at 860-774-7650.

Existing clients with a new pet are to call or text the office at 860-774-7650 to schedule an appointment.

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