InformationDate of Admission AppointmentMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet's Name(Required) First Last Owner's Name(Required) First Last Does your pet ever go outside?(Required) Yes No What food do you currently feed, including regular treats:(Required) How frequently and how much do you feed this pet?(Required) What is your pet’s heartworm prevention medication and when was the most recent dose given?(Required) What is your pet’s flea & tick prevention medication and when was the most recent dose given?(Required) Is your pet on any additional medications or supplements on a regular basis?(Required) Yes No If yes, please describe medication/supplement name, frequency of administration, and most recent dose: **Required vaccinations for “Day Admission Appointments”: Canine Vaccinations: up-to-date Bordetella, Distemper, and Rabies Feline Vaccinations: up-to-date Distemper and Rabies *All pets who participate in day admission visits must be free of external parasites such as fleas and ticks. If your pet is found to have either of these parasites while in our care, your pet will be treated at the owner’s expense.Primary Reason For VisitPlease state what your primary concern is for your sick pet today in the box below. List in detail the problem or concern, along with when did this start and is it getting better/worse/or stayed the same.(Required) Does your pet have any chronic medical conditions such as kidney disease, diabetes, hypothyroid?(Required) Yes No If yes, explain here: Has your pet had any changes in their diet recently?(Required) Yes No If yes, explain here: Could your pet have gotten into anything like the trash or chewed/eaten things they shouldn’t?(Required) Yes No If yes, explain here: Has your pet been in any social situations lately (dog parks, daycare, boarding, grooming)?(Required) Yes No If yes, explain here: Have you noticed vomiting or diarrhea?(Required) Yes No Are they sneezing or coughing?(Required) Yes No If yes, explain here: How much are they eating?(Required) Less than normal Normal More than normal How much are they drinking?(Required) Less than normal Normal More than normal Any changes in urinating or defecating habits?(Required) Yes No If yes, choose from the following options: Less than normal Normal More than normal If your pet is having urinary issues, have you seen evidence of blood in their urine?(Required) Yes No Is your pet itching their skin or ears more than normal?(Required) Yes No Is there anything else we need to know about your pet’s recent medical history? Treatment and Diagnostics:We will often recommend additional diagnostics to adequately treat your pet. Can we begin these prior to calling you if needed?(Required) Yes No Do you authorize blood testing to check for abnormalities? (if your pet is being seen for an illness, this testing is vital to gaining further insight into your pet's illness)(Required) Yes No Do you authorize radiographs of your pet, if deemed necessary by the veterinarian?(Required) Yes No Sedation may be required to further treat your pet (pick one of the following options):(Required) The doctor has my permission to sedate my pet, if needed Please call me prior to sedation, if warranted Do you authorize a urinalysis test to be performed? (if your pet is being seen for urinary concerns this is required)(Required) Yes No Notice to Pet Owners: Our Day Admission Appointments typically require your pet to be in our care for much of the day with most discharges being done between the hours of 4:30pm and 6pm. If deemed necessary due to the nature of the Day Admission visit, we may require a deposit at the time if drop off.Best Contact Number to communicate treatment and diagnosis results:(Required)Best Contact Number for pick up:(Required)Owner’s authorization for treatment and care: By signing your name below, you acknowledge that you are financially responsible for all treatment and care provided to your pet during their visit. As well as, acknowledging that you have read and understood this information on this document.Signature(Required) Δ
