"*" indicates required fields Animal Care HospitalAdmissions FormThe information requested tells us the things you want us to do for your pet while in our care. It is the only way we can be certain that we understand what you want. Therefore, it is very important for you to be as specific as possible. If we need additional information, we need to be able to reach you at the number you give us today. Thank you.Owner’s Name* First Last Email Address* Pet's Name*Pet's Age*Reason for Visit?*Where were Vaccinations Done?*Is your pet micro-chipped?* Yes No Would you like to microchip your pet today?* Yes No Is your pet sick?* Yes No Is your pet spayed/neuter?* Yes No Currently on Heartworm Preventative?* Yes No Type*History - Please Fill Out CompletelyIf your pet is showing signs of illness, please carefully observe and note the symptoms you have observed. Use the text field provided when selecting a checkbox to provide additional details, such as duration, description of symptoms, and any other relevant information. Symptoms Change in Appetite or Water Intake Vomiting, Diarrhea, Bad Breath Listless or Weak Coughing, Sneezing, or Gagging Change in Urination or Defecation Scratching, Chewing, Shaking Head, Scooting Limping Unusual Lumps or Bumps Weight Loss or Gain Unusual Discharge Behavioral Changes Explain:Change in Appetite or Water IntakeExplain:Vomiting, Diarrhea, Bad BreathExplain:Listless or WeakExplain:Coughing, Sneezing, or GaggingExplain:Change in Urination or DefecationExplain:Scratching, Chewing, Shaking Head, ScootingWhich Leg?LimpingExplain:Unusual Lumps or BumpsExplain:Weight Loss or GainFrom Where?Unusual DischargeExplain:Behavioral ChangesAnything Else We Need To Know?May we sedate your pet if necessary?* Yes No Call First After examination, may we proceed with tests and/or treatments?* Yes No Call First Animal Care Hospital will use all precaution against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. I am the owner or responsible agent of the above named animal and hereby authorize the performance of the procedures as marked above. I understand that any quotes or estimates given for services to be performed are ONLY ESTIMATES, and I take full responsibility for payment of charges. Payment is due when services are rendered. It is also understood that if I do not pay this account as agreed that past due accounts are subject to costs of collection.Date* MM slash DD slash YYYY Signature of Owner or Agent*Phone Number where you can be reached Today:*Accept* I understand that evidence of fleas/ticks will be treated if present and agree to pay for the extra charge incurred.Accept* I do not hold Animal Care Hospital responsible in any way for any illness contracted if my pet has only been vaccinated in the last 72 hours.Accept* If you have any questions concerning fees, please check with the receptionist PRIOR to services being performed.
