Patient Check-in/Drop off admission form

Patient check-in/ Drop off form

Pre check-in form

Name*
First Last
Appointment Date*
Date Format: MM slash DD slash YYYY
Pets Name*
First
Age*
Please enter a number from 0 to 22.
Sex*
Contact Information
* If your pet is a drop here for a drop off appointment today we will need to be able to contact you or someone with permission to make medical and financial decisions regarding your pet. Please list below who we will be in contact with during todays appointment.
Primary Contact Name*
First Last
Phone Number*
Secondary Contact Name (if we are unable to reach you)*
First Last
Phone Number*
Would you prefer a text when your pet(s) exam is completed?*
- Yes
- No
- N/A
Appointment Information
Reason For visit: Select ALL that apply*
- Vaccines/Wellness
- Surgical Consult
- Dental Evaluation
- Comprehensive Exam
- Behavioral Consult
- Weight Mgt or Nutritional questions
- Injury
- Illness
- Rehabilitation Consult
If injury, illness or other was selected please write a brief description:
Additional concerns: Select ALL that apply
- Eating
- Drinking
- Bowl movements
- Urinating
- Weight loss
- Vomiting
- Diarrhea
- Coughing
- Sneezing
- Weight Gain / Loss
- Bad Breath
- Drooling
- Lethargy
- Restless
- Itching/Scratching
- Smelly ears
- Scooting
- Behavioral Changes
- Discharge
- Other
Additional comments on reason for visit or concerns:
Did your pet eat this morning?*
- Yes
- No
If yes, at what time?
Medications / Supplements / Prevention:
Please complete the following questions to the best of your ability.
Is your pet on any prescription medications at home?*
- Yes
- No
If yes, what? And when was the last dose?
Medication: Last dose given:
Supplements/Over the counter medications?*
- Yes
- No
If yes, what?
Supplement:
Does your pet have any allergies?*
- Yes
- No
If yes, to what?
Is your pet on flea tick and heartworm prevention?*
- Yes
- No
If yes, what products?
Flea/Tick prevention Heartworm Prevention
Refill Requests for today
Do you need any medication/supplements refilled for your pet today?*
- Yes
- No
If yes, what?
Medication/ Supplement
Do you need a refill of your pets flea/tick prevention?*
- Yes
- No
Do you need a refill of your pets heartworm prevention?*
- Yes
- No
Patient History
Please complete the following questions to the best of your ability.
Has your pet ever had an adverse reaction to any medications?*
- Yes
- No
Has your pet ever had an adverse reaction to any medications?*
- Yes
- No
If so, explain:
Does your pet have any previous health concerns or diagnosis that we should know about?*
- Yes
- No
If so, explain:
Do you have any other pets?*
- Yes
- No
If so please list them below.
Services
Are there any services that you would like done during your pet(s) visit?
Please select all that apply.
(NOTE: Additional costs will apply with services chosen.)
- Nail trim
- Fecal exam
- Ear Cleaning
- Microchip application
- Anal glands
- Brush out
- Tooth brushing
- Sanitary trim
- Other
If "other" was selected please write the service you would like to have completed.
CONSENT
Information for visiting pets. Please read and check the provided box*
*A flea control product will be administered to pets with live fleas. This makes your pet more
comfortable and protects our hospital and other patients from possible flea infestation.*
When given, a charge will appear on your statement.
By checking this box you understand give permission to treat.
CONSENT
Emergency /Urgent / or Surgical cases. Please read and initial.
Preanesthetic Blood panel:*
This is performed for every patient and is included in the estimate for every
general anesthetic procedure. Some abnormal results may warrant additional testing, and your medical
team will contact you to discuss additional evaluation. In some instances, the anesthetic procedure may
be postponed or cancelled.
By checking this box you understand and give permission to treat.
Critical Intervention:*
Critical intervention may be needed to maintain normal heart rate, blood pressure and oxygen levels. In those situations, client permission for critical intervention may not be immediately obtained and additional charges may apply.
By checking this box you understand and give permission to treat.
Diagnostic testing:
Diagnostic testing may help us detect any problems that are not found on the physical exams. Once the exam is completed by the doctor, our hospital will contact you prior to conducting any further testing. At the time of contact, if necessary, we will offer a treatment plan that will help us provide a diagnosis for your pet.
By checking this box you understand and give permission to treat.