Patient Admission Form--Annual

Date

Name

First NameLast Name

Pet's Name

First NameLast Name

What is the best number for us to contact on the day of your pet's appointment? Please have voicemail activated on your phone.

Area CodePhone Number

Email

example@example.com

All dogs must be brought on a leash, and all cats must be brought in a carrier.

IF you are dropping off your pet, please make sure you are available by phone so the team can reach you with any questions after the exam. We are open Monday-Friday 8:00 a.m.-6:00 p.m. We close for lunch from 1-230pm. Once the doctor has contacted you to let you know your pet is ready to go home, they must be picked up before close or they will incur an overnight boarding fee.

Please provide stool and urine samples at your appointment time O or IF you have a drop off appointmet. Both samples must be refrigerated within 30 minutes of collection; stool samples must be less than 8 hours old, and urine samples must be less than 12 hours old. We cannot accept urine samples in paper towels, litter, etc.

We understand that a urine sample may be hard to obtain on your own. Please do not allow your pet to urinate before bringing into building (from your car to building). We can get the sample for you.

If fleas are found on your pet, we reserve the right to treat for fleas in-hospital. We will administer a CapStar tablet orally in the event that fleas are found.

By clicking here, you agree and understand that your pet must be up-to-date on all required vaccinations in order to be dropped off. For cats: rabies, FVRCP. For dogs: rabies, distemper-parvo (dhpp), and bordetella (kennel cough). If your pet is not up-to-date, the required vaccination(s) will be updated at this visit at the veterinarian's discretion.

Would you like us to call if any treatments that go beyond annual services are recommended?

If this is your pet's first visit with us, what is the name of their previous vet? Have they had vaccines before? If so, please list.

What concerns do you have for your pet that you would like the doctor to know?

Is your pet having any of the following? Check all that apply.

If yes to any of the above, please provide a brief description.

Is your pet on heartworm prevention? Name of product?

Is your pet on flea prevention? Name of product?

Is your pet on any daily medications (y/n) ? If so, please list name(s) of medication(s), strength, and last time you pet received any medication(s).

Does your pet need any refills of any current medication or prescription diet food? (e.g. heart worm and flea prevention or

If yes, please list any medications that need refilling.

Is your pet mainly indoor or outdoor?

What type of food do you feed you pet? How much do you feed?

Our doctors recommend annual lab work for dogs and cats. Basic Wellness testing is recommended for animals 7 years and younger. Comprehensive Wellness is recommended for healthy animals 8 years and older. We believe that preventative medicine is extremely useful. Checking baseline lab work in an adult or senior pet, even if outwardly healthy, can not only verify that a pet is truly healthy, but in some cases can shed light on a possible underlying medical condition for which the pet is not yet showing symptoms.

Please note that if you pet is sick or injured, the doctor may want to run different diagnostics for better medical assessment.

Please note the prices below are only for the wellness lab panels themselves and do not include the cost of the exam or any other services rendered during the appointment.

Please run Basic Wellness Profile for my pet who is 7 years and younger ($126):

Please run Comprehensive Wellness Profile for my pet who is 8 years and older ($255 for dogs; $301for cats due to the inclusion of Free T4 for early detection of hyperthyroidism): (please note that this panel is valid for annual appointments only)

I have read and understand that if I selected "yes" to either of the above, I am aware of and responsible for their respective additional charges.

Would you like your pet to have any additional services today such as a nail trim/anal gland expression/etc.?

Would you like your pet microchipped today ($82)

I understand that there will be a charge of $30 if I do not show up for my appointment or I cancel appointment less than 24 business hours.

Signature

Please verify that you are human