Southern Crossing AH - Patient Admission Form

1
Date* This field is required.
Date
Month
Day
Year
2
Client / Pet Information* This field is required.
Owner’s Name
Patient’s Name
Phone Number
Email
3
What time will you be picking up your pet?* This field is required.{Pick up must be by 6:00pm. A $35 late fee will be applied if picked up later than 6:15pm.}
4
Please describe in detail any problems present
5
6
Do you authorize reasonable workup (Lab work, x-rays, etc)?
Yes
No
7
Do you authorize sedation if needed?
Yes
No
8
Annual Exam - Authorization
YesNo
YesNo
YesNo
YesNo
YesNo
Canine Annual vaccinations *if needed {Vaccines, Heartworm/fecal test, physical exam}?
Feline Annual vaccinations *if needed {Vaccines, Fecal test, physical exam}?
Feline Annual leukemia/FIV test *if needed?
Wellness blood work {CBC, Chemistry profile, total T4, Urinalysis}? [ Blood work is additional charge: Dogs: $93/$160/$165 Cats: $92/$149/$185 ]
Would you like your pet to be microchipped with a HomeAgain Microchip?
Canine Annual vaccinations *if needed {Vaccines, Heartworm/fecal test, physical exam}?
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 5
9
Do you need to refill heartworm prevention(Heartgard or Proheart) or fleaprevention (Nexgard)?
10
Do you need to pick up any medications/food today?
11
Are you dropping your pet off for a bath/nail trim:
Yes
No
12
Admission Policy
All animals admitted to the hospital must be current on all required vaccinations and free of external parasites, i.e. fleas and ticks. I hereby give permission to the staff of SCAH to update my pet’s vaccinations if necessary and to treat any external parasitism noted. I understand that I will be financially responsible for these services. SCAH is not staffed after hours. If your pet requires overnight care, you will be referred to Animal Emergency Center.

I understand that all fees are due at the time that services are rendered. In the event of default or failure to pay, I the undersigned, agree to pay all attorney fees and the collection cost of said debt.

Owner/Agent Signature Signature *
Should be Empty:

Admission Policy