General admitting form Client Name(Required) First Last Pet Name(Required)What concerns you about your pet today?(Required)How long has this problem been going on?(Required)Is there any pertinent medical history? (previous surgeries, treatments, diagnosis, etc.)(Required)Is your pet spayed/neutered?(Required) YES NOIs your pet microchipped?(Required) YES NODoes your pet have a history of seizures?(Required) YES NOIs your pet experiencing any of the following symptoms? Please mark all that apply.(Required) Vomiting Diarrhea Coughing Sneezing Lethargy Loss of appetite Increased water consumption Inappropriate urination/bowel movements Weight fluctuations Changes in eating habits Trouble chewing Change in sleeping habits Waking in the middle of the night Restlessness Lameness in any limbs Trouble walking Pain getting up Unwillingness to go for walks or play Unusual vocalizations Boredom Anxiety, fear or stress Disorientation or balance issues Change in social habits Seizures Other (Please Specify Below) NoneIf your pet is experiencing any symptoms, please provide more details here: (how long, how often, how bad, etc)(Required)Could your pet have had exposure to toxins? (pesticides, cleaning products, plants, etc.)(Required)Does your pet have any allergies? Please describe. (medications, food, environment, etc.)(Required)Has your pet ever had an adverse reaction to a vaccine or medication? Please describe.(Required)Is your pet currently taking any medication? Please list the medication, dose and time last given. Please do not write "On File". We need to verify that the medications you are actually giving your pet matches what we have on file.(Required)MedicationDoseTime last given Add RemoveWhat brand of food do you feed your pet? How much and how often?(Required)Does your pet have access to: (mark all that apply)(Required) Inside only Outside, supervised Outside, unsupervised Dog parks, daycare or boarding Open spaces (wooded, tall grass, streams, lakes, etc.)What brand of flea/tick prevention is your pet on?(Required) Bravecto Revolution or Revolution Plus Simparica or Simparica Trio NexGard or NexGard Combo/Plus Frontline Seresto Collar None OtherWhat brand of heartworm prevention is your pet on?(Required) Proheart-12 Injections Revolution Plus Simparica Trio NexGard Combo/Plus Heartgard Milbeguard None OtherWhat brand of litter do you use? (for dogs, please enter N/A)(Required)Are there any other pets at home? How many and what species?(Required)Does your pet get along well with everyone in the household? (pets and people)(Required)Does your pet have any behavioral problems? Please describe.(Required)Do you have pet insurance?(Required) YES NOIs there anything else you feel we need to be aware of?I agree to pay all charges for services provided by Martinez Animal Hospital upon discharge of my pet. Payments can be made by most major credit cards, Care Credit or cash. A credit card processing fee of up to 3% will be applied to all transactions made using credit/debit cards.(Required) I UNDERSTANDI understand and accept the clinic's cancellation policy, which requires a minimum of 24 hours' notice for cancellations; otherwise, a cancellation fee may apply.(Required) I UNDERSTANDI acknowledge the clinic's late policy, which states that while efforts will be made to accommodate appointments, if I am more than 10 minutes late, Martinez Animal Hospital may not be able to provide services, and a $10 late fee may apply.(Required) I UNDERSTANDFor inpatient appointments: If we find fleas on your pet during their hospitalization, we will administer CapStar flea treatment. You are responsible for the cost of treatment.(Required) I UNDERSTANDFor inpatient appointments: In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked.(Required)Signature
