Name *

First

Last

Primary Phone *

Secondary Phone

Email *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Who will we be speaking with today? *

Myself
Someone Else

Name *

First

Last

Primary Phone *

Secondary Phone

Car make, model, and color that you will arrive/arrived in *

Reason for visit (check all that apply): *

Recheck w/doctor
Continuing hospitalization
Surgical procedure
New problem

If you are checking in for a surgical appointment please fill out our Surgical Admission Form .

If new problem, please explain *

Has your pet been seen at another clinic since their last visit with us? *

Yes
No

Name of veterinary clinic *

Will your pet be staying with us today? *

Yes
No

Has your pet improved since your last visit? *

Yes
No

If no, please explain *

Have you noticed any new symptoms? *

Yes
No

If yes, please explain *

What kind of food are you feeding? *

Has your pet had any other food but their own? *

Yes
No

If yes, please explain *

When did your pet last eat? *

When did your pet last drink? *

Is your pet having normal stools and urinating regularly? *

Yes
No

If no, please explain *

How is your pets activity level? *

Normal
Abnormal

If abnormal, please explain *

Is your pet currently taking any medication? *

Yes
No

Medication Name *

Last dose given *

Is your pet currently taking any additional medication? *

Yes
No

Medication Name *

Last dose given *

Is your pet currently taking any additional medication? *

Yes
No

Medication Name *

Last dose given *

If your pet has fleas, they will be given a Capstar at your expense.

Has your pet ever had an adverse reaction to a medication? *

Yes
No

If yes, please explain *

Is it ok to sedate/put under anesthesia if necessary? (understand there are always inherent risks, including death): *

Yes
No

In order for our doctors to do a complete analysis for diagnosis, do we have permission to perform the following if needed?:

Please note: Pre-anesthetic blood work checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform blood work prior to anesthesia or sedation.

Full CBC/Chem 17/Lytes – $195 *

I give permission to perform
I do not give permission to perform

Full bloodwork an all major organs and full red and white blood cell count; indicated for longer anesthetic procedures and sick patients.

*Required for pets over the age of 8 years old* NOTE – We may require this blood work for some procedures and situations.

Partial Chem/CBC/Lytes – $167 *
I give permission to perform
I do not give permission to perform
Basic internal organ screen (liver, kidneys) with full red and white blood cell count; for generally healthy, younger patients.

*Required for pets over the age of 5 years old*

Ultrasound - $360 *
I give permission to perform
I do not give permission to perform
An estimate will be given if an ultrasound is needed.

Radiographs (2 views) - $175 *
I give permission to perform
I do not give permission to perform

Urinalysis - $74 *
I give permission to perform
I do not give permission to perform

CPR Consent: I, the owner/agent understand that the therapeutic, anesthetic, or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s), staff, and Island Pet Veterinary conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. *We will administer CPR treatment unless declined. * *
I accept
I decline

I, the owner/agent for the pet described above, request and authorize an exam for my pet. I have read and understand all of the information listed in this form. I understand that the staff at Island Pet Veterinary will contact me at the number listed above after my pet has been examined to discuss diagnosis and treatment, and will have an initial estimate of charges.

I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

Signature *

Clear Signature

Date *

Recheck Exam Admission Form

Complete this form if you’ve had an appointment within the last 30 days.