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)General appearance/attitude?(Required)Is there any pertinent medical history? (previous surgeries, treatments, diagnosis, etc.)(Required)Is your pet experiencing any of the following symptoms? Please mark all that apply. 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)If your pet is experiencing any symptoms, please provide more details here: (how long, how often, how bad, etc)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.MedicationDoseTime last given Add RemoveCould your pet have had exposure to toxins? (pesticides, cleaning products, plants, etc.)Do you need any additional services today, including medication refills or written prescriptions? (Note, we cannot guarantee we will be able to accommodate last minute requests)Is there anything else you feel we need to be aware of?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)Do you want to receive text communications? YES NOA credit card processing fee of up to 3% will be applied to all transactions made using credit/debit cards. If you wish to avoid this fee, you may pay with cash, check or Care Credit. PAYMENT IS DUE AT TIME OF SERVICE, PLEASE COME PREPARED.(Required) I UNDERSTANDSignature
