Admission Form Step 1 of 250%Pet Name*Owner* First Last Date Of Appointment* MM slash DD slash YYYY Please leave 2 telephone numbers where you can be reached today:*What is the reason for today’s visit?*When did your pet eat last?*Did your pet receive their medication(s) this morning?* Yes No N/A If no, when did they receive their medication(s) last?Additional Information*I, the undersigned, certify that I am the owner, or authorized agent for the owner of the animal described above. I authorize the veterinarian and assistants of Mahomet Animal Hospital to perform the procedures listed above. I release Mahomet Animal Hospital and its associates from any liability in such an event, i.e. injury, escape, death, or any other unforeseen circumstances. I also understand that no guarantee of successful treatment can be made. In the event of an emergency I authorize the veterinarian and assistants to provide any and all treatments/procedures deemed necessary and accept responsibility for any additional cost incurred. (Signature)*Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Account balances will be charged a $1 statement handling fee and 2% interest accrued monthly.Medical HistorySeizures? Yes No Heart problems? Yes No Allergic reactions? Yes No Drug allergies or reactions? Yes No If yes, what drug(s)?Diabetic? Yes No If yes, what type of insulin and units are given?Other serious or chronic medical issues? Yes No If yes, describeAny illness/trauma (vomiting/diarrhea, coughing, accident) in the past 30 days? Yes No Sedation HistorySedated previously? Yes No If yes, any problems?MedicationCurrently on medication(s) other than heartworm and flea/tick prevention? Yes No If yes, any problems?Heartworm prevention (dogs only)Current on heartworm prevention? Yes No If yes, what was the last date given?Flea MedicationCurrent on flea medication? Yes No If yes, what brand and when was it last applied?Vaccination HistoryCurrent on vaccinations? If your pet is new to our hospital, please bring in vaccination records to your appointment. Yes No *If no, vaccinations may be required. Do you want vaccinations updated?Additional services Nail trim Microchip ($45, including lifetime registration) Express anal glands ($18 - $20) Other If otherYour pet will need to be fasted for their procedure. No food after 10 pm the night before, including no breakfast the morning of. Water is ok. Owner’s Digital SignatureCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
