Fecal & UA Drop Off Form Time collected: (<1 hr.)Dropped off:Refrigerated:YesNoPlease be aware it may take up to 24hours to hear from us with the results.Owner Name:Patient Name:Client NumberPhone Number:Staff InitialsProblem give details: Is this a recheck Urinalysis or fecal:YesNoHave the symptoms been resolved?How long has it been a problem?Straining?YesNoFrequency?IncreasedDecreasedSameBlood?YesNoMucus?YesNoVaginal discharge? ( applies to a female patient with urinary tract symptoms)YesNoIncreased licking of the vulva or prepuce? (applies to female/male with urinary tract symptoms)YesNoIf this is a fecal test, the consistency of the fecal matter: 1. Watery. 2. Cow Pie. 3. Soft Ice CreamIs your pet having accidents in the house?YesNoBrand of Food:Change in food or dietary indiscretion:” Got in the trash etc.”Eating and Drinking normal?YesNoActivity normal?YesNoVomitingYesNoDo you already have a appointmentYesNoOn Any Medication or supplements (including over-the-counter medications/aspirin/other and prescribed medications/supplements)DoseFinished AntibioticsYesNoNA
