Family name: ______________________________________________ Date: _______________________________
Name of dog:______________________________________________ Age: _______________________________
How long have you provided health care for this family's animals?: _________________________________________
Good health and medical condition prior to this accident/illness?: __________________________________________
Diagnosis and date:
____________________________________________________________________________
____________________________________________________________________________________________
Proposed
course of treatment:
_____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Prognosis with proposed treatment:
_________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Prognosis w/o proposed treatment (either no
treatment at all or alternative treatment):
___________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list any alternative treatments for this dog, and, if possible,
pros and cons of these treatments: _______________
____________________________________________________________________________________________
____________________________________________________________________________________________
Estimated cost of proposed treatment: _______________________________________________________________
Please list any
follow-up or additional care that will be required (physical therapy for
example) or any other information you feel is pertinent to
this case: __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I Certify that the above information is accurate to the best of my knowledge and is furnished to BEHAF at the request of the owner of the above dog.
Signature: ____________________________________________ Date:
_____________________________________
Typed
name of treating Veterinarian:
__________________________________________________________________
Please mail this completed
form to Ruth Nielsen, Nielsen Law Office Inc., P.S., 927 N. Northlake Way Suite 301, Seattle, WA 98103-1119.
Thank you for your assistance.
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