Elkridge Animal Hospital: Blood Glucose Curve Admission Form

Please take some time to complete this form as accurately as possible.

While your pet is here today, we will periodically check their blood glucose levels. The last glucose reading that we will take is typically around 6PM. Unless otherwise stated, your pet will be ready for pick up between 6:30PM - 7PM.

Owner's Name *

First Name Last Name

Pet's Name *

How many units of insulin is your pet currently receiving? *

How long have they been at this dose? *

When was the last dose administered? *

When did your pet last eat? *

What type of food and how much? *

Did you have any concerns that you would like the veterinarian to address while your pet is here today?

Yes No

Please explain or list the concerns about your pet that you would like to be evaluated:

Are there any other services you would like performed today?

Nail trim Clean ears Check anal glands I decline all elective services.

Description

Price

Blood Glucose Curve

Hospitalization (Level 1): > 6 hours

$110

Incl.

During the treatment of your pet additional charges may arise due to various reasons such as additional medications or supplies required for the best treatment of them. The staff of Elkridge Animal Hospital will do their best to inform me of any additional charges but I understand that this may not always be feasible.

It is the policy of the Elkridge Animal Hospital to NOT provide credit under any circumstances, and we therefore remind all clients that payment in full is due at the time of discharge. For your convenience payment can be made by cash, credit card, and check. All reasonable precautions will be taken against injury or escape of the pet but the EAH will not be liable or responsible to any persons under any circumstances for or on account of the care, treatment or safekeeping of any animal or articles left with the animals, or otherwise in connection therewith. The owner assumes all risk. This facility does not have 24-hour personnel on site.

I hereby authorize Elkridge Animal Hospital to perform a glucose curve on my pet. I have had the charges explained to me and I understand I am responsible for payment at discharge. *

Clear

Date *

Date