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Wake County Animal Shelter/Control Form
15
Questions
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1
Admission Date
*
This field is required.
-
Date
Year
Month
Day
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2
Admission Time
*
This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
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7
8
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11
12
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
AM
AM
PM
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3
*
This field is required.
Dr.
Tech
Patient ID/Name
Acct #
Patient #
Species #
Breed #
Please Select
Male
Female
Please Select
Please Select
Male
Female
Sex
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4
Color
Age
Weight
Officer Name
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5
Email
*
This field is required.
example@example.com
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6
I authorize that WAKE COUNTY ANIMAL CONTROL has taken ownership of this animal prior to admittance to Animal Emergency Hospital & Urgent Care
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7
I authorize Animal Emergency Hospital & Urgent Care to humanely euthanize this animal
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8
Officer picked up stray
From Shelter
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9
Microchip scanned
Tech initials
Please Select
EUTH
TREATING
Please Select
Please Select
EUTH
TREATING
Checked/Logged in Hospital Lost & Found
Please Select
EUTH
TREATING
Please Select
Please Select
EUTH
TREATING
Checked/Logged in Triangle Lost Pets
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10
**
Call Dr. Federico for any treatments/estimates over $100-—Cell:
(919) 270-3976
**
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11
Objective
T
HR : bpm
RR: bpm
MM
CRT
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12
Presenting Complaint/History
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13
Wake County Account
**Call Wake County Animal Control for p/u (not RAC)**
Call Dr. Federico
Charges Entered
Approve Invoice
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14
Dr. Signature
*
This field is required.
Clear
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15
*
This field is required.
Scan
Fax
Drugs Logged
Flowsheet
Dr. Finished
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