Owner Name

Email Address:

Pet Name

THIS FORM WILL NOT BE PROCESSED WITHOUT NAME INFORMATION FILLED OUT!

Please provide a fresh sample. Samples should be the size of a tootsie roll. If unable to bring sample in right away place sample in a bag and place in your refrigerator until you bring it into the clinic (less than 10 hours old)

Please answer the following questions:

Is your pet having any of the following symptoms?

Diarrhea

Vomiting

Lethargy

Weight loss

Weight gain

Decreased activity

Change in daily routine

If change in daily routine, please explain:

When did you first start seeing signs/symptoms?

Has your pet had any accidents in the house?

Yes

Does your pet go outside (FELINE)?

Yes

How many times per day has your pet been going?

What does your pet's stool look like? (watery, soft, solid, etc.)

Have you noticed anything in your pet's stool? (blood, mucus, parasites, objects, etc.)

Last time your pet had abnormal stools?

Do you see your pet straining?

Yes

Is your pet still urinating ok?

Yes

How many pets do you have in your household? (cats, dogs, other)

Are any of the other pets with similar symptoms?

Yes

Has your pet eaten or gotten into anything inside or outside?

Yes

Any changes in your pet's food?

Yes

Does your pet eat any people food or table scraps?

Yes

What brand of food does your dog eat?

Any change in appetite or thirst?

Have you recently had any new stresses in your life? (moved/new home, new baby or pet, new job schedule, etc.) If yes, please explain:

Is your pet currently on any medications or supplements?

Any other questions or concerns?

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Fecal Drop-off Form

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