Drop Off Admission Form Drop Off Admission Form 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 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: * What medications is your pet currently taking and when was the last time they were administered? * Any Home Treatments: At discharge, would you like to: * Receive a discharge phone call from doctor Receive a discharge phone call from a technician 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. Signature * signature keyboard Clear Phone number where you can be reached today: * Submit If you are human, leave this field blank.
