InformationDate of Admission AppointmentMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pet'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 VisitDoes your pet have any chronic medical conditions such as kidney disease, diabetes, hypothyroid?(Required) Yes No If yes, explain here: Has your pet been in any social situations lately (dog parks, daycare, boarding, grooming)?(Required) Yes No Is there anything else we need to know about your pet’s recent medical history, such as new lumps/bumps or issues that need to be addressed during their appointment?(Required) Do you authorize annual bloodwork to be sent out?(Required) Yes No Do you need refills of chronic medications or preventions at this visit?*(Required) Yes No If yes, please explain: *Some medications require routine bloodwork prior to medication refills. If deemed necessary, there may be additional charges applicable* 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
