Patient Admitting Form Client’s Name* First Last Patient Name*Species*DogCatWhat concerns you about your pet today?*How long has this problem been going on?*Is your pet*IndoorOutdoorBothAre there any other problems?*YesNoIs there any vomiting*YesNoIs there any diarrhea*YesNoIs there any coughing*YesNoIs there any sneezing*YesNoIf yes, for how long?Is your pet eating*YesNoIs your pet drinking*YesNoIs your pet urinating normally*YesNoIf not, for how long?What is your pet’s diet including name brand?*Is your pet currently taking any medication?*YesNoIf yes, what medication and dosageWas medication given today?*YesNoTimeIs your pet on consistent flea control?*YesNoIf yes, which one?Is your pet micro chipped?*YesNoIs your pet current on its rabies vaccination?*YesNoHas your pet had a fecal analysis in the last 6 months?*YesNo. Is your pet on consistent heartworm prevention?*YesNoIf yes, which one?. Are there other pets at home?*YesNoIf yes, what kindDog(s)Cat(s)Do you authorize blood work*YesNoDo you authorize x-rays*YesNoDo you authorize sedation*YesNoDo you authorize anesthetic*YesNoDo 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.**Please note*: Minimum charge today will be: For inpatient (day stay) exam: $85.00 For urgent-care inpatient exam: $110.00In 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 #Additional information or comments:***Please note**: If your pet is found to have fleas, we will apply flea treatment at your expenseSignature*Date* NameThis field is for validation purposes and should be left unchanged.
