Well 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 pick up? * This field is required.{Pickup must be before 6:00pm. A $39.50 late fee will apply if picked up after 6:15pm}
4
Canine Annual
5
Canine Wellness Diagnostics
6
Feline Annual
7
Feline Wellness Diagnostics
8
Do you authorize sedation if necessary?*Additional charge: price varies according to weight
Yes
No
Call First
9
Do you have any other questions or concerns about your pet today?
Yes
No
10
Is your pet on any medications or supplements?
What food(s) does your pet eat?
11
Does your pet get groomed, board or go to daycare anywhere?
Yes
No
12
Does your pet need prevention?
Yes
No
13
Which prevention does your pet need
Heartgard
Nexgard
Nexgard Plus
ProHeart 12
Revolution Plus
14
Do you need to pick up any medications or food today?
Yes
No
15
Are you dropping your pet off for a bath/nail trim?
Yes
No
16
Admissions Policy
All animals admitted to the hospital must be up to date on all required vaccinations and free of external parasites, i.e. fleas and ticks. I hereby give permission to SCAH staff to update my pet's vaccinations if necessary and to treat any observed external parasitism. I understand that I will be financially responsible for these services. SCAH does not have after-hours staff. If your pet requires overnight care, they will be referred to the Animal Emergency Center.

I understand that all fees are due at the time the services are rendered. In the event of default or non-payment, I, the undersigned, agree to pay all attorney's fees and the cost of collecting such debt.

Owner/Agent Signature Signature *
Should be Empty:

Admissions Policy