Drop Off Admission Online Form

Date

Owner's Name

First Last

Pet Name

First Last

Species

Breed

Sex

Male
Female

DOB:

The information you provide below will let us know the best way to help your pet and how to exceed your expectations. It is important to be as accurate and as thorough as possible. Please leave 2 telephone number where you can be reached today:

Phone

Please leave 2 telephone number where you can be reached today:

Phone

Your pet will receive a physical exam today ($66). We will call you to discuss our findings and recommendations. We will go over any further estimated costs for services/diagnostics.

What is the reason for today's visit?

Did your pet eat this morning?

Yes
No

If yes, what time?

: HH

MM

Is your pet sick?

Yes
No

If yes, what is the major complaint?

Has your pet been treated for this condition before?

Yes
No

If yes, when?

Current Diet

Number of feedings / day

Is he/she given table scraps?

Yes
No

Is your pet on heartworm preventative?

Yes
No

Flea/ Tick Preventative?

Yes
No

Is your pet currently on any medications?

Yes
No

If yes, please list medication name, dose, how much you give, and how often.

Do you need refills on any of this medication?

Yes
No

If yes, please specify:

Is your pet diabetic?

Yes
No

If yes, did they receive insulin this morning?

Yes
No

If yes, at what time?

: HH

MM

Type? How many units?

Is your pet scratching, shaking head or scooting?

Yes
No

If yes, how long and where?

All pets admitted in to Healthy Pet Hospital & Grooming must be up to date on vaccines. If done elsewhere, we will need to have proof of vaccines. Is your pet current on all required vaccines?

Yes
No

If no, please see reception.

How is your pet feeling? Below are a few signs to indicate.

Change in appetite?

Yes
No

If yes, please check the relevant words / phrases

Not eating at all
Decreased appetite
Will eat treats only
Eating more than usual
Diet change

Change in drinking?

Yes
No

If yes, please check relevant words/phrases:

Drinking more
Drinking less
Not drinking at all

Vomitting?

Yes
No

If yes, please check relevant words/phrases:

White
Yellow
Pink
Food
Got into trash
Recent diet change
History of hairballs
History of eatting toys or string
Vomit more that 2x/month

Diarrhea?

Yes
No

If yes, please check relevant words/phrases:

Watery
Blood tinged
Bloody
Mucous

Change in urination?

Yes
No

If yes, please check relevant words/phrases?

Bloody
Increased frequency
Increased amount of urine
Smaller amount of urine but more frequent
Urinating out of box
Straining
Vocalizing
Accidents at home
Licking vulva/penis

Coughing or sneezing?

Yes
No

If yes, please check relevant words/phrases:

Moist
Dry
Honking
Occurs at night
Occurs during the day
Seasonal

Lumps/Bumps? Please describe:

Some diagnostic tests help us in detecting problems that are not found on a physical examination. We will contact you following your pet's physical examination and provide an estimate for recommended testing.

Additional services requested today:

Ear Cleaning
Nail Trim
Vaccination Update
Fecal
Microchipping
Anal Gland Expression
Heartworm Test
Other

If other, please specify:

I authorize Pet Hospital to perform the procedures as indicated above. I understand the doctor or technician will contact me after my pet has been examined to discuss recommended tests, which may include x-rays and bloodwork along with a recommended treatment plan. I understand that the doctor will not proceed with any tests, or treament until I have given verbal or signed authorization to the recommendations and estimate given to me. I authorize the hospital staff, in an emergency situation, to perform any additional procedures necessary for the well-being of my pet until further communication with me. I understand that payment is due in full at the time of discharge. I understand that follow-up examinations and additional treatments are not covered in today's total. I understand that no guarantee for successful results is made.

By checking the below box, I have read and understand the above information and sign off.

Agree

Contact Us

The information you provide below will let us know the best way to help your pet and how to exceed your expectations. It is important to be as accurate and as thorough as possible. Please leave 2 telephone number where you can be reached today:

How is your pet feeling? Below are a few signs to indicate.

Some diagnostic tests help us in detecting problems that are not found on a physical examination. We will contact you following your pet's physical examination and provide an estimate for recommended testing.

In this section

My Pet’s Medical Records

Pet Health Articles

Map & Directions

Forms Of Payment Available:

Subscribe to our Newsletter and Weekly Specials

Drop Off Admission Online Form

The information you provide below will let us know the best way to help your pet and how to exceed your expectations. It is important to be as accurate and as thorough as possible. Please leave 2 telephone number where you can be reached today:

How is your pet feeling? Below are a few signs to indicate.

Some diagnostic tests help us in detecting problems that are not found on a physical examination. We will contact you following your pet's physical examination and provide an estimate for recommended testing.

Share

In this section

My Pet’s Medical Records

Pet Health Articles

Map & Directions

Forms Of Payment Available:

Subscribe to our Newsletter and Weekly Specials