Drop Off Admission Form Drop Off Admission Form Today's Date Owner Information Name * Name First First Last Last Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Has your address or phone number changed? * Yes No Pet Information Pet's Name * Age * Your Pet has had the following vaccinations: * Your pet must be current in order to stay here with us. The information requested below will tell us the things you want us to do for your pet. It is the only way we can be certain that we understand what you want. Therefore, it is very important for you to be as specific as possible. If we need additional information, we will try to reach you at the phone number you’ve left today. What procedure(s) would you like done for your pet today? * Please describe any problems your pet is experiencing. * Last Time Symptoms Noted and How Long: Last Time Pet Ate and How Much: * Coughing * Yes No How long have they been coughing? * Sneezing * Yes No How long have they been sneezing? * Vomiting * Yes No How long have they been vomiting? * Diarrhea/Loose stools * Yes No How long have they had diarrhea/loose stools? * Lethargy * Yes No How long have they been lethargic? * Eating normally * Yes No How long have they been eating normally? * Growths/Bumps * Yes No How long have they had Growths/Bumps? * Is your pet currently taking any medications? * Yes No Medication(s) Please list all medications, directions, and last time administered Medication * Directions * Last time administered * 121234567891011 : 00153045 AMPM plus1 Add minus1 Remove Any Home Treatments: At discharge, would you like to: * Schedule a discharge appointment with doctor Schedule a discharge appointment with a Technician Receive a discharge phone call from doctor Receive a discharge phone call from a technician Additional Services Anal gland expression $52.40 Ear cleaning $69 Microchipping – Permanent Microchip Identification System designed to identify lost pets and reunite them with their owner. (First year registration included. $19.99 savings.) $73 + tax * I would like my pet microchipped today. No or Already Chipped Sedation: If sedation is required for your pet, would you like any of the following procedures performed X-Rays * While your pet is under anesthesia it is a great time to perform x-rays for general wellness in our senior pets or to assess hips in younger pets. Price includes interpretation by a board certified radiologist. (price varies $201-$366) No Nail Trim (includes tax) * I would like my pet's nails cut today. $22+tax I would like my pet's nails cut and filed while he/she is asleep. This procedure rounds the edges of the nail so they are not as sharp. $42+tax I would like my pet’s nails cut past the quick while he/she is asleep. This procedure is ideal for dogs whose nails are too long. A topical anesthetic is applied to lessen pain and stop the bleeding. (This procedure will not be performed without anesthesia and will require pain meds to go home) $65+tax NO, I do not want my pet’s nails trimmed. Medical Release I release Advanced Pet Care of Clear Lake from the loss or expense these actions might incur upon me, provided said actions are necessary to preserve the life of my pet. While your pet is here being treated, you may initially receive a call from a technician with a treatment plan. At any time if there are further questions, you may request a call from the Doctor. Please allow adequate time for the Doctor to call you back depending on the clinic’s schedule. We make every effort to call you in a timely manner.I understand any problem that develops with my pet while I’m absent will be treated as deemed best by the staff veterinarian and I assume full responsibility for the treatment expense involved. If you have any further questions please ask. * I agree Authorization to perform surgery / or treatment I authorize the veterinarians and staff of Advanced Pet Care of Clear Lake to perform the procedure is described above. I understand that unforeseen complications may arise during the anesthetic period, including loss of life. I acknowledge and understand that no guarantee or warranty can ethically be made regarding results or outcome of this case. In the event of an emergency, I authorize the clinic staff to perform any procedures they feel are necessary for the well being of my pet until communication is established with me. I understand that I assume financial responsibility for all services rendered. * I agree Signature * signature keyboard Clear Phone number where you can be reached today: * Secondary # if unable to reach you (if applicable): * Email * Does your Pet Require an ELIZABETHAN CONE Collar?: * Yes No You may bring one from home to be evaluated by the doctor for proper fitting in relation to the procedure that will be performed. One can be provided for you if you do not have one or the one brought does not fit the requirements * I have a collar at home I do not have a collar at home Submit If you are human, leave this field blank.
