Glucose Curve (Home or In-Clinic) – Access Veterinary Care

Your Name: (First & Last): *

Patient: *

Email *

Phone #: *

Primary Veterinarian: *

Insulin type/brand: *

Current insulin dose (units per 12 hours): *

Are you bring your pet in for a glucose curve, or submitting results from home? *

In-Clinic Glucose Curve

Submitting Home Curve Results

Current thirst and urine output (vs. normal / pre-diabetes): * Current thirst and urine output (vs. normal / pre-diabetes):

Current appetite: * Current appetite:

Describe their current attitude/activity level. Any other new concerns? *

Drop-off for Glucose Curve

Did your pet eat this morning? *

Yes

No

What time did they eat? *

NOTE: Always bring a small amount of your pet’s usual diet when dropping off for a glucose curve.

Has your pet received their insulin this morning? *

Yes

No

Your pet must receive insulin to perform this test. You may bring the insulin and a small amount of their normal food to the appointment and we can give it on arrival if needed.

What time did they receive insulin? *

Any additional services you’d like performed today (vaccines if dues, microchipping, nail trims, etc.):

List any medication or supply refills you need today:

By signing below, I acknowledge that I have received and accepted an estimate of costs, have had the opportunity to ask questions to my satisfaction, and am approving the recommend diagnostics, services, or treatments.

Signature *

Clear

Date *

Home Curve

Payment: *

I have already paid

Please call for payment ($39)

Date of curve: *

Time(s) insulin was given during curve & number of units: *

Time(s) pet ate on day of curve: *

Enter each time and blood glucose value below (ex: 8:20AM, 158), then click “add value” for each additional reading.

Glucose Reading *

Add Value Remove