Diabetic Day Admission
This form is for pets needing to be dropped off at the clinic for examination.
Owner's Full Name
*
First Name
Last Name
Pet's Name
*
Reason for Visit
*
Give the main reason for the visit. Give additional information as appropriate. For example, "drop-off for glucose curve because my cat is drinking more water" or "glucose curve recommended per veterinarian".
Phone Number where I can be reached during the day
*
-
Area Code
Phone Number
When was your pet's last meal and how much did your pet eat?
eg: last night, most of the kibble and all of the canned
Diet
What type of food do you feed your pet?
When was your pet's last insulin injection?
*
eg: last night at 7pm
Please list type of insulin, dosage and frequency
*
eg: glargine, 2 units twice a day
What other medications or supplements do you give your pet?
Rows
Medication Name
Dosage
Frequency
Refill Needed (Y/ N)
#1
#2
#3
Has your pet been showing lethargy?
*
Yes
No
Has your pet been stumbling?
*
Yes
No
Has your pet had muscle tremors?
*
Yes
No
Has your pet's appetite been normal?
*
Yes
No
The amount of water my pet has been drinking is....
*
Normal
Increased
Decreased
The amount my pet has been urinating is....
*
Normal
Increased
Decreased
Any other information to share with us?
Permanent Identification Microchip Placement Requested
Yes ($58)
No, Thank you
My pet already has a microchip.
Nail Trim Requested
Yes ($16.50)
No
After your pet has been examined, the veterinarian will call you at the number given above. In the event the doctor is unable to reach you:
*
The doctor may proceed with the indicated treatment and care of your pet as long as the cost is within the amount entered below.
Do not proceed with any treatment until the doctor is able to reach me.
If proceeding with treatment, cost is approved up to this dollar amount:
*
Submit
Should be Empty: