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Feline Admission Form
Conveniently fill out our Feline Admission Form online.
Owner's Name
(Required)
First
Last
Email
(Required)
Pet's Name
(Required)
Name
Phone Number
(Required)
History
Reason for exam/visit?
If your pet is ill, when did you first notice the symptoms?
Is your pet:
Indoors
Outdoors
Both
Has your pet had an exam with a veterinarian in the last year?
Yes
No
If yes, where?
Are your pet's vaccinations current?
Yes
No
If yes, where were they given?
Has your pet had any decrease in appetite?
Yes
No
Has your pet had any decrease in activity level?
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 coughing?
Yes
No
Has your pet had any sneezing?
Yes
No
Has your pet had any vomiting?
Yes
No
Has your pet had any diarrhea?
Yes
No
Has your pet eaten today?
Yes
No
If yes, what time?
What medication has your pet been given today?
Does your pet have any lumps/growths you would like us to look at?
Yes
No
If yes, where?
Would you like our pet bathed?
Yes
No
Would you like your pet to have a nail trim?
Yes
No
When was your pet last given a flea/tick prevention?
Name of product used?
Would you like a Google Micro-chip ID?
Yes
No
Has your pet been tested for Heartworm Disease?
Yes
No
When was your pet last given a heartworm preventative?
Name of product used?
Has your pet ever had a dental exam?
Yes
No
Would you like more information about our dental procedures?
Yes
No
Consent
(Required)
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.
Yes, I agree
*Any pet found to have internal or external parasites will be treated at the client's expense.*
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