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Home Forms ACTH Drop-Off Form

ACTH Drop-Off Form

"*" indicates required fields

Date*

MM slash DD slash YYYY

Pet Name*

Who should the Doctor contact today to discuss findings?*

Phone*

Unavailable Times*

What size Trilostane (Vetoryl) capsule(s) does your dog receive?*

120

How many times per day?*

Once

Twice

What time did your dog get the capsule this morning?*

Was the Trilostane given with a full meal?*

Yes

I don’t know

Has your dog had any urinary accidents/leakage within the past month?*

Yes, but less than before

Yes, same as before

Yes, more than before

Drinking & Urination?*

Drinks/Urinates normal amount

Drinks and urinates more

Constantly drinking and urinating

Rate your dog's appetite change since the beginning of treatment*

Increased

About the same

A little less

A lot less

Appearance*

Normal

Slightly poor hair/skin quality

Poor hair quality +/- slight potbelly

Substantial hair loss +/-

Attitude/Activity*

Normal

Not quite themselves

Not themselves +/- panting at rest

Not themselves, weak +/- constant panting

Has your dog had any vomiting/diarrhea/trembling other signs of illness since your last visit? If yes, please provide details including what clinical signs were present, when it happened, how long it lasted and if you gave any medications*

Signature*

Printed Name*

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Name

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13217 Midlothian Turnpike,
Midlothian, VA 23113

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13217 Midlothian Turnpike,
Midlothian, VA 23113

Home
Our Hospital
Services
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New Patients
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Online Pharmacy
Contact Us

Make an Appointment

(804) 794-3778

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