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152 Sparrowbush Road, Latham, New York 12110

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518.783.3198

518.783.3199

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Emergency & Critical Care

Home » Form: Emergency Triage Form

Form: Emergency Triage Form

We understand bringing your pet to the emergency room is stressful. Please complete this form with as much detail as possible. Details will help us provide the best care for your pet. Your completed form will be sent directly to our emergency team for review and further triage.

Client Information

Date(Required)

Month

Day

Year

Client Name(Required)

First Last

Pet's Name(Required)

Phone(Required)

Please provide the best phone number to reach you.

Triage/History

What problem/concern are you here for today?(Required)

When did this start?(Required)

When was the last time you saw your primary care veterinarian?(Required)

Has your pet seen your primary care veterinarian for this specific issue?(Required)

Is your pet eating/drinking?(Required)

No

More

Less

Is your pet lethargic?(Required)

Yes

No

Are they vomiting?(Required)

Yes

No

Are they having diarrhea?(Required)

Yes

No

Are they coughing?(Required)

Yes

No

Are they sneezing?(Required)

Yes

No

Are they drinking and/or urinating more than usual?(Required)

No

More

Less

Has your pet gotten into anything they shouldn't have?(Required)

For example - unusual food, medications, toxins, possibly ingested foreign material that could be causing an obstruction?

Yes

No

If yes, what and when?

When was the last time your pet received vaccinations?(Required)

Is your pet indoors only?(Required)

Yes

No

Has your pet ever been sick or had any major injuries or surgeries before?(Required)

Yes

No

If yes, please explain:

Is your pet on any medications or supplements?(Required)

Yes

No

If yes, please list the following:

Use the plus sign to add another medication or supplement

Name

Dose

Last time given

Has your pet had a previous reaction to any medications, anesthesia, etc.?(Required)

Yes

No

If yes, please explain:

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Hours of Operation

Specialty Services: Monday – Friday 8am-6pm
*Subject to change during Holidays

Emergency Service: 24 hours a day / 7 days a week

Upstate Veterinary Specialties, PLLC

152 Sparrowbush Road, Latham, New York 12110
Phone: 518.783.3198 Fax: 518.783.3199

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