Patient Admit Form Pet's Name: * Owner's Name: * First Name Last Name Phone * (###) ### #### Email * What is your primary concern(s) today? * Please list all concerns. I authorize the veterinarian to perform the following relevant tests (check all that you authorize): * Blood test for Heartworm Disease/Tick Born Diseases at an additional cost of $40.00 Option 2Basic bloodwork (CBC/Blood Chemistry) at an additional cost of $130.00 Urinalysis and Sedimentation at an additional cost of $45.00 Radiographs of the suspected problem area at an additional cost of $145.00 + $35.00 per additional How would you describe your pet’s attitude? (check all that apply) * Anxious More excitable More mellow Grumpy Lethargic What symptoms of illness or injury is your pet showing? (check all that apply) Weight loss Weight gain Coughing or wheezing Sneezing Difficulty breathing Shaking head Discharge from eyes Drooling Foul breath Constipation Straining to defecate Blood in stool Increased appetite Increased or decreased drinking Vomiting How often? Diarrhea How often? Option 1 Option 2 Choose one: Watery Pudding Consistency Somewhat Soft Loss of appetite When did your pet last eat, what was it, and how much? Problems with urination (check all that apply) Difficulty or straining to urinate Increased frequency of urination Blood in urine Dribbling urine Urinating or defecating outside of litter box How often? Where? Changes in activity (check all that apply) Has gradually slowed down and become less active overall Sudden decrease in activity Limping Has stopped grooming themselves Difficulty (Check all that apply) Rising Jumping Walking Running Crying or wincing when moving or touched Scratching themselves Visible fleas, ticks, or lice Seems Painful Location Seizure-like behaviors How often? How long do they last? Hair Loss Location(s): New or change in a lump or mass Location(s): Describe changes: When did you notice the change? Other information: Have there been any significant changes in the household? (Check one) Yes No If so, what are they? How long has the symptom(s) been occurring, or when did you first notice the problem? Is the problem: (Check one) Worsening Remaining the same Showing improvement? Please give any additional information that you can think the veterinarian or staff needs to know: Please enter your name and date as a signature to this form. * First Name Last Name Date * MM DD YYYY Thank you! We will email you if we have any questions.
