Owner Name *

First

Last

Owner Email *

Pet Name *

I understand that I am dropping off my pet in order to allow for him/her to be evaluated by a veterinarian sooner than an appointment is available and that there is not a designated appointment time for my pet. I understand that Bexley Animal Hospital will verify that my pet is stable upon arrival but he/she may not be fully evaluated until there is available time between scheduled appointments and therefore a pickup time for my pet cannot be predicted nor guaranteed. *

I have read and understand the above statement.

I understand that a doctor will call me when my pet is finished and a treatment plan will be discussed. I will do my best to be available via the phone number listed below in case of an emergency and to help my pet receive efficient and timely care. *

I have read and understand the above statement.

Please provide a phone number where you can be reached: *

I authorize the following procedures/diagnostics/treatments be performed if the doctor deems them necessary for the care of my pet:

Do you need any medication refills?

Yes
No

Please indicate what medications: *

Health Questionnaire

List of concerns to be addressed today:

List of medications your pet has received in the past 48 hours:

Describe your pet’s diet:

If your pet is a cat, does he/she go outside?

Yes
No

Is he/she supervised while outside?

Yes
No

Vomiting/Diarrhea: Is your pet experiencing either of these?

Yes
No

When did the issue start? *

Is your pet eating a normal amount?

Yes
No

Does your pet have a normal energy level?

Yes
No

Is your pet asking to go outside/pooping more frequently?

Yes
No

Urinary Issues: Is your pet having any urinary issues?

Yes
No

When did the issue start?

changes understand the

Is your pet urinating in the house/outside the litter box?

Yes
No

Is your pet urinating more frequently?

Yes
No

Have you noticed any blood in the urine?

Yes
No

Limping: Is your pet limping?

Yes
No

When did the issue start? *

Was there any known incident that initiated the limping?

Yes
No

Which leg do you believe is affected?

Skin Issues/Ear Infections/Itching/Lumps: Is your pet experiencing symptoms of these?

Yes
No

Is your pet itchy?

Yes
No

Please indicate where they are itchy: *

When was the last dose of flea prevention administered/applied?

Does your pet have these issues seasonally, year round, or is this the first incidence?

On a scale of 1-10, how itchy is your pet?

If a lump(s) is present that you are concerned about, where is it and have you noticed any changes to it?

Coughing/Sneezing/Nasal Discharge/Eye Issues: if your pet is experiencing any of these, please proceed:

Is your pet coughing?

Yes
No

When were they last at the kennel, groomer, dog park, or daycare?

Is your pet sneezing excessively?

Yes
No

Having nasal discharge?

Yes
No

Is your pet having eye discharge?

Yes
No

Squinting, pawing at the eyes, or rubbing face on floor?

Yes
No

Which eye is affected?

Left
Right
Both

Additional concerns/comments:

I understand that with any medical procedures, there are risks involved and I accept these risks. I further understand that no guarantee of successful treatment has been made. I assume full financial responsibility for all charges related to the treatment of my pet. *

I have read and understand the above statement.

If an emergency situation develops and I cannot be reached by the phone number listed, I authorize Bexley Animal Hospital to provide treatment to stabilize my pet *

I have read and understand the above statement.

Signature *

Clear Signature

Date *

Admission Information and Authorization to TreatForm

Complete theForm Below

Health Questionnaire

Coughing/Sneezing/Nasal Discharge/Eye Issues: if your pet is experiencing any of these, please proceed:

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