Day admission form

Day Admission

Canine or Feline
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?

Month Day Year
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.
Should be Empty:

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Day Admission