Day admission form

Client Name

First Name Last Name

Phone number to contact on the Day of Admission

Area Code Phone Number

Alternate phone number for contact

Area Code Phone Number

HAVE YOU BEEN EXPOSED TO SOMEONE WITH COVID?

Yes No

Email

example@example.com

How do you plan on paying for your invoice today?

Credit card Check Cash Care Credit

Do you have an appointment or are you here to be seen as a walk-in?

Appointment Walk-in

Pet's name and Date of Birth

Name Birth date

When did the problem start?

Date

Please describe primary reason for Appointment/Concerns

Is your pet Vomiting?

If yes, please describe below

Is your pet having Diarrhea?

If yes, please describe below

Have you given your pet any medication? If yes, please list what medication and when.

How is your pet EATING?

	1	2	3	4	5

1 is Eating LESS than usual, 5 is Eating MORE than usual

Is your pet more THIRSTY than usual?

	1	2	3	4	5

1 is Drinking LESS than usual, 5 is Drinking MORE than usual

Patient's energy level

	1	2	3	4	5

1 is Lethargic, 5 is Very active

Patient's Urination (select all that apply)

Normal Increased Decreased Blood present Dark Straining to urinate Strong/foul odor

Please rank how PAINFUL you think your pet is?

	1	2	3	4	5

1 is Not painful, 5 is Very painful

Is the patient on Heartworm Prevention?

Yes No I'm not sure

If your dog is on Heartworm Prevention, when was the last dose given?

Is the patient coughing or sneezing?

Do you need refills on any medications? If so, which ones?

What flea/tick preventive are you using?

Have you seen any fleas or ticks on your pet?

Yes No

Do you provide dental care for your pet? If yes, please describe below.

Yes No

If the patient is a cat, does he/she go outside?

Indoor only 50/50 Indoor/Outdoor Outdoor only My cat does have contact with other cats My cat does NOT have contact with other cats

What brand of food do you feed your pet and how much do you feed daily?

If the patient is a dog, does he/she go to the following:

Boarding facility Groomer Dog Park Obedience/Training class Have contact with any other dogs outside of house-mates

Please list any additional information we need to know.

As a part of making your pet's visit more enjoyable, we give many treats including cheese and peanut butter. Does your pet, or someone in your family have food allergies?

Yes. Please do not give my pet cheese or peanut butter. No. You are welcome to treat my pet to their heart's content!

Day Admission