Drop Off Admission Checklist

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Pet Name*

Breed

Age

Weight

Reason for admit appointment:

Is your pet on a special diet?*

YesNo

If so, please list diet:

Is your pet taking any medications, preventatives, over-the-counter medications, or topical?*

YesNo

If yes, list medications, dosage, and time last given: *

Annual vaccines: Would you like to have these updated?*

YesNo

Select all vaccines and/or tests you would like updated:

If we find parasites, may we deworm your pet?

YesNo

Do you need an estimate or more information on any services today?

YesNo

Do we have your permission to perform diagnostics such as lab work, x-rays, etc. if pertinent to your pet's visit?*

YesNo

Are there any concerns you need to address with the doctor or procedures you would like performed?

List any personal items you will be leaving with your pet today:

Please note:

A topical treatment will be applied, at the owner's expense, to any pet with evidence of fleas, flea dirt, or ticks.
An Elizabethan Collar may be required for your pet's comfort and protection. Prices vary according to size.
For the comfort of your pet, pain medication is given for all surgical procedures.

Authorization

I verify I am the owner (or authorized agent for the owner) of the named pet and authorize the above procedure to be performed by New Baltimore Animal Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.

I have been advised as to the nature of the treatments to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthetic episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. Procedure risks include serious bodily injury, (including, but not limited to: eye injuries, broken teeth, broken jaw) or death. I understand it may be necessary to provide medical and/or surgical procedures, which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges.

I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24-hour hospital).

In the event of an unforeseen emergency, we will attempt to reach you without delay. Very rarely do emergencies happen and we want to know your preference if no one can be reached. Please select your preference below:*

Please proceed with extreme life-saving measures(CPR and resuscitation drugs).I accept responsibility of all costs incurred.Please DO NOT proceed with extreme life-saving measures. I accept responsibility for all costs incurred.

Contact Name

First NameLast Name

Date

Phone Number

Area CodePhone Number

Please list any other contact phone number and times you may be available should the we need to contact you.

Please be prepared to pick up your pet by 5:30 p.m.

Owner/Owner's Agent Signature:

Admitted by: