HOSPITAL ADMISSION FORM

If possible, we would appreciate it if you would fill out our hospital admission form prior to your arrival.

Downloadable form:
Animal Emergency & Critical Care Admissions Form

Required fields [*]

GENERAL INFORMATION

Email [*]

Owner [*]

Date

Mailing Address [*]

City [*]

State [*]

Zip Code[*]

Home Phone

Work Phone

Cell Phone

Pet's Name

Breed

Type
DogCatFerretGuineaRabbitBirdReptileOther

QUESTIONS

Please answer these questions to the best of your ability.

1. Have you been here before?
Yes No

2. All medications or home remedies your pet has received or is currently taking.

3. Has your pet had its vaccines (shots) this year?
Yes No

3.1. If not, has your pet ever had shots?
Yes No

4. Is your pet on heart worm prevention?
Yes No

5. List what your pet has eaten (or may have eaten) in the past 2 days.

6. Is your pet vomiting?
Yes No

7. ls your pet coughing?
Yes No

8. Does your pet have diarrhea?
Yes No

9. How is your pet urinating?
Normal Not urinating More than normal

10. Anything Else?

PLEASE READ THE FOLLOWING CAREFULLY.

I. I hereby authorize the doctor on duty, and assistants the doctor may designate, to perform a physical exam on the above described animal(s) and to provide an estimate for recommended services and treatment.

2. I understand that emergency patients must be removed from the clinic daily no later than 30 minutes prior to closing, (7:30 AM Monday-Saturday). I agree that any patient not removed shall be deemed to have been abandoned. Once the animal has been abandoned, Animal Emergency & Critical Care has the responsibility for the animal and will treat or dispose of it as we see fit.

3. I understand that my pet(s) will receive emergency treatment only and that he/she/they may be released before all medical problems are known or treated. I will arrange for follow up treatment as instructed.

4. I understand payment in full is due at the time of service.

Accept these terms and conditions