FairleaAnimalHospital
Drop-off Admission Form
FELINE
Owner Information
Name ______Address ______Phone Number______Phone Number(s) where you can be reached today ______
Pet Information
Name ______
Why are we examining your pet today? ______
If your pet is ill, when did you first notice the symptoms?______
Is your pet (circle one) Indoors only Outdoors only Both indoors and outdoors
If indoors, is your pet going outside the litter box or in any other area of the house?
Yes No ______
Has your pet had an exam with the veterinarian in the last year? Yes No If yes, was it here? Yes No
Are all your pet’s vaccinations current? Yes No Were they given here? Yes No If not where were they received? ______
Has your pet been Feline Leukemia/FIV Tested? Yes No If not, would you like your pet to be? Yes No
Has your pet had any decrease in appetite? Yes No
Has your pet had any increase in thirst? Yes No
Has your pet had any increase in urination? Yes No
Has your pet had any decrease in activity level? Yes No
Has your pet had any coughing or sneezing? Yes No
Has your pet eaten today? Yes No If yes, what time? ______
What medications (if any) have you given your pet today?
______What time? ______
Has your pet had any vomiting or diarrhea? Yes No
If yes, when and how much?______
Does your pet have any lumps or growths you would like us to look at? Yes No
If yes, where?______
Do you need a price estimate prior to any procedures? Yes No Call me first
Is it OK to sedate or anesthetize your pet if needed? Yes No Call me first
Would you like a flea treatment? (ask staff for current price) Yes No
Has your pet ever had a dental exam? Yes No Would you like more information about Dentals? Yes No
Would you like a HomeAgain Microchip ID? ($63.60 which includes first year
enrollment fee) Yes No
I, the undersigned owner or authorized agent of the above patient, hereby authorize the staff of Fairlea Animal Hospital to administer necessary treatment and to perform medical procedures. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made. I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release.
Signature of owner/agent______Date ______
Signature of Clinic Tech ______Date ______