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2525 HWY 25E | Middlesboro, KY 40965

606-248-4243

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Owner Name*
First Last
Pet Name*
Please provide the date of your appointment*
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Please provide the time of your appointment*
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Is your pet enrolled in pet insurance?*
- Yes
- No
Current Diet*
Current medications*
Current supplements*
Current flea control*
Current heartworm prevention*
Does your pet have any increase in drinking, urination, coughing, sneezing, vomiting, diarrhea, or panting?*
- Yes
- No
Please explain*
Is your pet currently eating/drinking? When was the last time your pet ate?*
Please list any chronic medical conditions, or reaction to drugs, supplements, or food that your pet has:*
Why are you bringing in your pet today?*
When did the problem start?*
Has this problem happened before?*
- Yes
- No
Have you tried any measures on your own to assist the problem?*
- Yes
- No
Please explain:*
Has your pet been to another veterinarian for this problem? If so when and can we contact the veterinarian for records?*
Is there any specific information about this problem that you feel is important to note?*
- Yes
- No
Please elaborate:*
Is there something important about your pet that you feel that we need to know?*
- Yes
- No
Please elaborate:*
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Bell County Animal Clinic

2525 HWY 25E

Middlesboro, KY 40965

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Bell County Animal Clinic

2525 HWY 25E
Middlesboro, KY 40965

Hours

MON – FRI: 8am – 6pm
SAT: 8:30am – 12:30pm
SUN: Closed

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