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ER Vets4pets - Raleigh Animal Control Intake Form (New)
25
Questions
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1
Date
*
This field is required.
-
Date
Year
Month
Day
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2
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
9
10
11
12
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
PM
AM
PM
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3
*
This field is required.
Acct #
Patient#
Name
Species
Breed
Please Select
Male
Female
Please Select
Please Select
Male
Female
Sex
Color
Weight (lbs./grams/kgs.)
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4
Dr.
Tech
Officer Name
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5
Owners Email
*
This field is required.
example@example.com
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6
I authorize that Raleigh Animal Control is surrendering ownership of this animal to Animal Emergency Hospital & Urgent Care and that they will take full responsibility for its care. In addition, I authorize Animal Emergency Hospital & Urgent Care to humanely euthanize this animal if indicated
*
This field is required.
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7
Microchip
Yes
No
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8
Microchip Info
Microchip#
Tech
Please Select
Check/Logged in Lost & Found binder
Checked/Logged in Triangle Lost Pets
Please Select
Please Select
Check/Logged in Lost & Found binder
Checked/Logged in Triangle Lost Pets
Check/Logged
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9
EUTH
TREAT
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10
EUTH
< 10# AC Euthanasia
> 10# AC Euthanasia
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11
TREAT
Switched to Good Sam account
Shelter/Rescue contacted
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12
Non-rabies Vector Wildlife
EUTH
REHAB
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13
EUTH
< 10# AC Euthanasia
> 10# AC Euthanasia
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14
REHAB
Wildlife form completed
Switched to Good Sam account
Rehabber contacted
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15
Rabies Vector Wildlife
< 10# AC Euthanasia
>10# AC Euthanasia
Contact RAC to collect body
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16
T:
HR:
RR:
MM:
CRT:
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17
Presenting Complaint/History
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18
Scan
Drugs Logged
Flowsheet
Dr. Finished
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19
Name
First Name
Last Name
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20
Phone
Species
Breed
Age
Sex
Weight
Client#
Patient#
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21
DNR / CPR
Painful / Fractious
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22
Allergy
Problem
Estimate
Belongings
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23
Drug
Bottle #
Time
Amount
Log
ezyVet
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
11
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
12
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Row 11, Column 5
1
2
3
4
5
6
7
8
9
10
11
12
Drug
Row 0, Column 0
Bottle #
Row 0, Column 1
Time
Row 0, Column 2
Amount
Row 0, Column 3
Log
Row 0, Column 4
ezyVet
Row 0, Column 5
Drug
Row 1, Column 0
Bottle #
Row 1, Column 1
Time
Row 1, Column 2
Amount
Row 1, Column 3
Log
Row 1, Column 4
ezyVet
Row 1, Column 5
Drug
Row 2, Column 0
Bottle #
Row 2, Column 1
Time
Row 2, Column 2
Amount
Row 2, Column 3
Log
Row 2, Column 4
ezyVet
Row 2, Column 5
Drug
Row 3, Column 0
Bottle #
Row 3, Column 1
Time
Row 3, Column 2
Amount
Row 3, Column 3
Log
Row 3, Column 4
ezyVet
Row 3, Column 5
Drug
Row 4, Column 0
Bottle #
Row 4, Column 1
Time
Row 4, Column 2
Amount
Row 4, Column 3
Log
Row 4, Column 4
ezyVet
Row 4, Column 5
Drug
Row 5, Column 0
Bottle #
Row 5, Column 1
Time
Row 5, Column 2
Amount
Row 5, Column 3
Log
Row 5, Column 4
ezyVet
Row 5, Column 5
Drug
Row 6, Column 0
Bottle #
Row 6, Column 1
Time
Row 6, Column 2
Amount
Row 6, Column 3
Log
Row 6, Column 4
ezyVet
Row 6, Column 5
Drug
Row 7, Column 0
Bottle #
Row 7, Column 1
Time
Row 7, Column 2
Amount
Row 7, Column 3
Log
Row 7, Column 4
ezyVet
Row 7, Column 5
Drug
Row 8, Column 0
Bottle #
Row 8, Column 1
Time
Row 8, Column 2
Amount
Row 8, Column 3
Log
Row 8, Column 4
ezyVet
Row 8, Column 5
Drug
Row 9, Column 0
Bottle #
Row 9, Column 1
Time
Row 9, Column 2
Amount
Row 9, Column 3
Log
Row 9, Column 4
ezyVet
Row 9, Column 5
Drug
Row 10, Column 0
Bottle #
Row 10, Column 1
Time
Row 10, Column 2
Amount
Row 10, Column 3
Log
Row 10, Column 4
ezyVet
Row 10, Column 5
Drug
Row 11, Column 0
Bottle #
Row 11, Column 1
Time
Row 11, Column 2
Amount
Row 11, Column 3
Log
Row 11, Column 4
ezyVet
Row 11, Column 5
1
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24
Critical Care Monitoring
Time
Temp
HR
RR
MM/CRT
BG
Pulse Ox
BP
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
5
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
6
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
7
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Row 5, Column 7
8
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Row 6, Column 7
9
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Row 7, Column 7
10
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Row 8, Column 7
1
2
3
5
6
7
8
9
10
Time
Row 0, Column 0
Temp
Row 0, Column 1
HR
Row 0, Column 2
RR
Row 0, Column 3
MM/CRT
Row 0, Column 4
BG
Row 0, Column 5
Pulse Ox
Row 0, Column 6
BP
Row 0, Column 7
Time
Row 1, Column 0
Temp
Row 1, Column 1
HR
Row 1, Column 2
RR
Row 1, Column 3
MM/CRT
Row 1, Column 4
BG
Row 1, Column 5
Pulse Ox
Row 1, Column 6
BP
Row 1, Column 7
Time
Row 2, Column 0
Temp
Row 2, Column 1
HR
Row 2, Column 2
RR
Row 2, Column 3
MM/CRT
Row 2, Column 4
BG
Row 2, Column 5
Pulse Ox
Row 2, Column 6
BP
Row 2, Column 7
Time
Row 3, Column 0
Temp
Row 3, Column 1
HR
Row 3, Column 2
RR
Row 3, Column 3
MM/CRT
Row 3, Column 4
BG
Row 3, Column 5
Pulse Ox
Row 3, Column 6
BP
Row 3, Column 7
Time
Row 4, Column 0
Temp
Row 4, Column 1
HR
Row 4, Column 2
RR
Row 4, Column 3
MM/CRT
Row 4, Column 4
BG
Row 4, Column 5
Pulse Ox
Row 4, Column 6
BP
Row 4, Column 7
Time
Row 5, Column 0
Temp
Row 5, Column 1
HR
Row 5, Column 2
RR
Row 5, Column 3
MM/CRT
Row 5, Column 4
BG
Row 5, Column 5
Pulse Ox
Row 5, Column 6
BP
Row 5, Column 7
Time
Row 6, Column 0
Temp
Row 6, Column 1
HR
Row 6, Column 2
RR
Row 6, Column 3
MM/CRT
Row 6, Column 4
BG
Row 6, Column 5
Pulse Ox
Row 6, Column 6
BP
Row 6, Column 7
Time
Row 7, Column 0
Temp
Row 7, Column 1
HR
Row 7, Column 2
RR
Row 7, Column 3
MM/CRT
Row 7, Column 4
BG
Row 7, Column 5
Pulse Ox
Row 7, Column 6
BP
Row 7, Column 7
Time
Row 8, Column 0
Temp
Row 8, Column 1
HR
Row 8, Column 2
RR
Row 8, Column 3
MM/CRT
Row 8, Column 4
BG
Row 8, Column 5
Pulse Ox
Row 8, Column 6
BP
Row 8, Column 7
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25
Time
Medication
1
Row 0, Column 0
Row 0, Column 1
2
Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
5
Row 3, Column 0
Row 3, Column 1
6
Row 4, Column 0
Row 4, Column 1
7
Row 5, Column 0
Row 5, Column 1
8
Row 6, Column 0
Row 6, Column 1
1
2
3
5
6
7
8
Time
Row 0, Column 0
Medication
Row 0, Column 1
Time
Row 1, Column 0
Medication
Row 1, Column 1
Time
Row 2, Column 0
Medication
Row 2, Column 1
Time
Row 3, Column 0
Medication
Row 3, Column 1
Time
Row 4, Column 0
Medication
Row 4, Column 1
Time
Row 5, Column 0
Medication
Row 5, Column 1
Time
Row 6, Column 0
Medication
Row 6, Column 1
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