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Client Name *

Appointment Date *

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Address

Address Line 1

City

State

Zip Code

Email *

Phone *

Email Reminders *

Yes
No

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Daytime Name/Phone Number

(if different than above)

Reason pet is here: *

How long has this been going on? *

May we sedate your pet if the doctor deems it necessary? (additional Fee applies)

Yes
No

May we perform blood work/urine analysis if the doctor deems it necessary? (Additional fee applies)

Yes
No

May we perform x-rays if the doctor deems it necessary? (Additional fee applies)

Yes
No

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Is your pet on any medications? *

Yes
No

Did your pet have any medication today? *

Yes
No

Does your pet go outdoors? *

Yes
No

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Is your pet on flea medication? *

Yes
No

If my pet is found to have transmissible conditions (such as fleas, ticks, ear mites) I give my permission for treatment. (For the protection of all, patient cannot be admitted without this permission) (additional Fees apply) Please sign below.

Clear Signature

If your pet is not current on recommended and required vaccinations, I understand vaccinations will be administered today at the doctor's discretion (additional Fees apply) *

Clear Signature

(initial)

If your pet is not current on recommended and required vaccinations, I understand vaccinations will be administered today at the doctor's discretion (additional Fees apply) *

Clear Signature

(initial)

What brand of food do you feed? *

Grain free?

Yes
No

When did your pet last eat? *

Have you observed any of the following in the past week? (Please check all that apply)

If your pet is not microchipped, would you like us to implant one today for $54? *

Yes
No

Any additional questions or comments?

I understand that payment is due in full upon my pet’s discharge. My method of payment will be: *

Check
Debit/Credit Card
Cash
Care Credit Account

Signature *

Clear Signature

Date *

Drop-Off Admission Form

Contact

Location

Open Hours