New Client/Patient Form

MEDICAL ADMITTANCE INFORMATION

Client Name *

Prefix First Name Middle Name Last Name Suffix

Primary Contact Phone Number *

This is my: *

Secondary Phone Number

This is my:

Alternate Contact Name

Prefix First Name Last Name Relationship

Phone Number

This is a:

My alternate contact is authorized to make medical and financial decisions on my behalf (if no selection is made, only the client listed on record will be authorized to make decisions and pick up the pet).

YES, the person listed as my alternate contact is authorized. NO, the person listed as my alternate contact is NOT authorized. NO, the person listed as my alternate contact is NOT authorized to make decisions, but is authorized to pick up my pet.

Pet Name *

Age *

My Pet Currently Eats *

Brand, Dry/Canned, Amount & Frequency

When was your pet last OFFERED food? *

Please note date and approximate time

Appetite *

Increased Decreased Not Eating Normal

Water Intake *

Increased Decreased Normal

Activity Level *

Normal Mild Decrease Severe Decrease

Urination *

Normal Increased Volume Increased Frequency Blood Seen

Vomiting *

Bowel Movements *

Normal Diarrhea Blood Constipated Unsure

Current On Vaccines? *

Has your pet traveled outside of Western Washington? *

If your pet has traveled outside of Western, WA, when and where?

My pet is *

Does your dog have exposure to wildlife? *

Including raccoons, opossums, rats, etc.

Which of the below apply to your dog (please check all that apply): *

Boarding facilities (including boarding at Firgrove Veterinary Clinic) Grooming faclilites Dog Parks Doggy Daycare Obedience Classes Camping and/or hiking Spend time with children under the age of 6 n/a, my pet is a cat

How many dogs (total) are in your household? *

How many cats (total) are in your household? *

Please Describe Your Pet's Current Problem & Behavior Noticed *

Previous Medical Problems *

Current Medications/Supplements (Please include dose & frequency of medication) *

Please list any flea treatment/preventative your pet has received and when the last dose was given/applied. If none, note as such. *

While my pet is at Firgrove Veterinary Clinic, please:

Trim my pet's nails Express my pet's anal sacs Clean my pet's ears Microchip my pet Provide annual deworming Provide flea treatment

DIAGNOSTICS & FLUID CONSENT

Radiographs & Laboratory Test Consent *

YES, I authorize my pet to have the laboratory tests and radiographs the doctor feels are necessary for the treatment of my pet. NO, I request a telephone call before performing any radiographs or laboratory tests, except in emergency situations.

Intravenous and Subcutaneous Fluid Consent *

YES, I authorize the doctor to administer intravenous or subcutaneous fluids to my pet as are necessary for the treatment of my pet. NO, I request a telephone call before administering supplemental fluids, except in emergency situations.

I hereby authorize personnel of Firgrove Veterinary Hospital to administer treatment as is considered therapeutically necessary during the course of hospitalization. I also consent to the administration of such anesthetics and analgesics as are necessary for the diagnostic, medical or surgical procedures to be performed. *

I acknowledge that I have read this statement

HOSPITALIZATION RISK STATEMENT

In the event that your pet may be kept overnight, you should be aware of the accommodations we provide for your pet as well as any potential risks for injury that could occur. We make every effort to keep pets safe from harm and are housed separately from each other in a temperature controlled environment in a latched hospital kennel. Your pet will not be wearing any collars, leashes, harnesses or other apparel unless a doctor feels it is necessary for your pet's safety. Clean bedding will be provided as well as food and water if their medical situation allows it. Although your pet is confined, he/she can still injure themselves. Possible injuries include, but are not limited to: broken teeth, broken claws, ingestion of bedding material which could result in vomiting, diarrhea or an intestinal obstruction. An Elizabethan Collar may be worn to prevent the risk of opening an incision or removal of an IV catheter, however, there is always the risk of injury and/or death when any collar is worn in a cage. While Firgrove Veterinary Hospital is equipped with smoke detectors and a security alarm, there is also potential risk of fire and/or criminal activity. Firgrove Veterinary Hospital is not a 24 hour facility. In the event that your pet may require 24 hour care, we may recommend that you transfer your pet to an Animal Emergency Center. Pets may be kept in our hospital overnight to provide a comfortable and quiet recovery, but we do not have personnel present in our facility overnight to observe or treat your pet. You have the right to transfer the care of your pet to a board certified specialist or any other veterinary hospital of your choosing. I understand the planned anesthetic, and surgical, diagnostic or therapeutic procedures involve risks of complications, injury or even death, both from known and unknown causes and no warranty or guarantee has either been expressed or implied. Furthermore, I authorize the hospital staff in an emergency situation to follow through with procedures as necessary for the well-being of my pet.

I acknowledge that I have read this statement and understand that regardless of the outcome, I am responsible for the fees incurred. Firgrove Veterinary Hospital does not bill and all fees are to be paid in full at the time of service.

I understand that Firgrove Veterinary Clinic is not a 24 hour facility and that I have the right to transfer my pet to a 24 hour facility. Any costs associated with a transfer and the physical transfer of the patient are solely the responsibility of the owner or authorized agent. *

I acknowledge that I have read this statement

I understand that I am required to make a down-payment of 50% of the high-end estimate upon the admission of my pet and that payment for services rendered will be expected in full on discharge. We accept cash, checks, most major credit cards as well as Care Credit as forms of payment. *

I acknowledge that I have read this statement

Treatment Plan *

I have NOT received an estimate I have already received a verbal estimate I have already received a written estimate

If you have received an estimate already, please note estimated amount given.

If you have received a VERBAL estimate, please note who gave you the estimated amount.

Signature *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear

Printed Name Of Person Signing *

Date *