Patient Admitting Form – Recheck Client’s Name* First Last Patient Name*Species*DogCatWhat condition is being rechecked today?*How long have you been treating this problem?*Are there any other problems?*YesNoIf yes, please explainHas your pet’s condition improved?*YesNoHow do you feel the treatment(s) have been going? Any difficulties?*Is your pet eating*YesNoIs your pet drinking*YesNo. Are there other pets at home?*YesNoIf yes, what kindDog(s)Cat(s)Do you authorize treatment as deemed necessary by the doctor?*YesNoContact FirstI authorize Martinez Animal Hospital to charge up to $____________. Expenditures over that amount require my approval.*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.*Alternate #**Please note**: If your pet is found to have fleas, we will apply flea treatment at your expenseSignature*Date* EmailThis field is for validation purposes and should be left unchanged.