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Hospital Admission Form
Please complete this form 1-2 days prior to your pets’ appointment. This form is for current clients only.
Your Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Email
What is the best way to reach you?
*
Phone
Email
Pet Information
Pet Name
*
Pet Species
Dog
Cat
Rodent
Bird
Rabbit
Ferret
Other
If Other Please Specify
Pet’s Diet and Activity
How often do you feed your pet daily?
What type of food?
Wet
Dry
Both - Wet & Dry
Amount Per Feeding
Drinking
Normal
Increased
Decreased
Appetite
Normal
Increased
Decreased
Urination
Normal
Increased
Decreased
Defecation
Normal
Increased
Decreased
Procedure Questions
Did your pet eat after midnight last night?
Yes
No
If Yes, How Much?
Is your pet taking medication right now?
Yes
No
**UNLESS INSTRUCTED OTHERWISE, PLEASE CONTINUE TO ADMINISTER ALL NECESSARY MEDICATIONS THE EVENING BEFORE AND MORNING OF ADMISSION (I.E. INSULIN, HEART MEDICATIONS, ETC.). THANK YOU, IN ADVANCE, FOR YOUR COOPERATION**
If Yes, Medicated When, and How Often?
Is your pet allergic to any food or medication?
Yes
No
If yes, describe allergy
Has your pet had any illness/injury in the last year?
Yes
No
Is your pet taking heartworm prevention (e.g., Interceptor)?
Yes
No
If yes, date of last HW prevention dose
Is your pet taking flea/tick prevention (e.g., Bravecto)?
Yes
No
If yes, date of last flea/tick prevention dose
Would you like a microchip to be implanted today?
Yes
No
Please Check if any of the following has happened recently
Select all that apply
Vomiting
Sneezing
Gagging
Shaking of head
Scooting of rear
Diarrhea
Straining to Urinate
Bad Breath
Constipation
Behavioral Changes
Unusual Lumps/Bumps
Lameness
Had a seizure in the past
Scratching
Any Weakness
If Yes, Please Detail
E.g. lame in which leg, scratching where, weakness where
Anything else we need to know?
Disclaimer
*
I agree
**PLEASE REMEMBER YOUR PET SHOULD NOT EAT PAST MIDNIGHT THE NIGHT BEFORE ADMITTANCE. WATER IS OKAY OVERNIGHT BUT NO WATER IN THE MORNING. THANK YOU IN, ADVANCE, FOR YOUR COOPERATION**
Disclaimer
*
I agree
**UNLESS INSTRUCTED OTHERWISE, PLEASE CONTINUE TO ADMINISTER ALL NECESSARY MEDICATIONS THE EVENING BEFORE AND MORNING OF ADMISSION (I.E. INSULIN, HEART MEDICATIONS, ETC.). THANK YOU, IN ADVANCE, FOR YOUR COOPERATION**
View our
Disclaimer
and our
Terms and Conditions
Δ
New Clients
New Client Registration Form
About Us
Our Doctors
Virtual Tour
Services
Pet Lodging and Day Care Request
My Pet
My Pet’s Medical Records
Useful Pet Links
Interactive Animal
Pet Insurance
News
Contact Us
Request Services
Disclaimer
Term & Conditions
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