Sick Pet Admission Form in Lubbock, TX | Hub City Veterinary Clinic

Client Information
Client Name*
First Last
Client Phone*
Client Email
Patient Information
Pet's Name*
Breed*
Age*
Sex*
Reason for Visit*
Has your pet experienced these symptoms previously?*
- Yes
- No
When was the last episode?*
Did the symptoms resolve with treatment?*
- Yes
- No
Is your pet current on heartworm preventatives?*
- Yes
- No
Type*
- Injectable
- Oral
Frequency:*
- Every 6 Months
- Every 12 Months
Frequency:*
- Monthly
- Seasonally
Is your pet current on flea and tick preventatives?*
- Yes
- No
Type*
- Topical
- Oral
Frequency:*
- Monthly
- Seasonally
Is your pet currently taking any medications or supplements?*
- Yes
- No
Please List:*
Dietary Habits
What brand of food is your pet currently on?*
What type of food does your pet eat?*
- Canned
- Dry
Does your pet regularly receive treats?*
- Yes
- No
People food or table scraps?*
- Yes
- No
Please Explain:*
Pet Treats?
- Yes
- No
Please Explain:*
Have there been any recent changes to your pet’s dietary habits?*
- Yes
- No
Please Explain:*
Has your pet eaten today?*
- Yes
- No
How much?*
- Ate Well
- Ate Half
- Ate a little
Are there any changes in your pet’s water consumption?*
- Yes
- No
Increased or Decreased?*
- Increased
- Decreased
Severity?*
- Mild
- Drastically
Please select any of the following options which describe any problems your pet is currently exhibiting.
- Vomiting
- Diarrhea
- Changes in urinary habits
- Respiratory Issues
- Lameness or Possible Injury
When did the vomiting begin?*
How often is your pet vomiting?*
Did you observe a vomiting episode?*
When was the last time your pet vomited?*
Please make notes regarding appearance.*
When did the diarrhea begin?*
Please make notes regarding the appearance.*
How often is your pet having to go?*
Is your pet having accidents?*
- Yes
- No
Please Explain*
Are there changes in the frequency of urination?*
- Yes
- No
Increased or Decreased?*
- Increased
- Decreased
How often is your pet going?*
Are there changes in the amount of urine produced?*
- Yes
- No
Increased or Decreased?*
- Increased
- Decreased
Please Explain*
When did these issues begin?*
Sneezing or discharge from the nose or eyes?*
- Yes
- No
When did the sneezing start or the discharge appear?*
How often have you notice the sneezing?*
Please describe any discharge present.*
Coughing or gagging?*
- Yes
- No
When did the coughing start?*
How often have you noticed coughing?*
Is anything produced with your pet does this?*
- Yes
- No
Please Explain*
Lame (non-weight bearing)?*
- Yes
- No
Front or Rear?*
- Front
- Rear
Left or Right?*
- Left
- Right
When did this begin?*
Did you see any injury to the limb?*
- Yes
- No
Please Explain:*
Have there been any changes to the area/limb since this began?*
- Yes
- No
What type of changes?
- Swelling
- Changes in natural placement
- Other
Please Explain*
Does your pet have a history of similar injuries?*
- Yes
- No
Please Explain*
When was the last time your pet had a similar episode?*
Have you given any medications to help with pain or inflammation?*
- Yes
- No
What medication was given?*
How Much?*
When was the last dose?*
Limping?*
- Yes
- No
Front or Rear?*
- Front
- Rear
Right or Left?*
- Right
- Left
Do you see any injury to the limb?*
- Yes
- No
Please Explain*
When did this begin?*
Has the condition changed since you noticed your pet limping?*
- Yes
- No
How So?*
- Worsened
- Remained the same
- Improved some
Does your pet have a history of similar injuries?*
- Yes
- No
Please Explain:*
When was the last time your pet had a similar episode?*
Have you given any medications to help with pain or inflammation?*
- Yes
- No
What medication was given?*
How Much?*
When was the last dose?*
Sore or Tender?*
- Yes
- No
Where does your pet appear tender or sore?*
- Limb or Paw
- Back or Neck
- Other area
Front or Rear?*
- Front
- Rear
Right or Left?*
- Right
- Left
Please Explain*
When did this begin?*
Has the condition changed?*
- Yes
- No
How So?*
- Worsened
- Remained the same
- Improved some
Does your pet have a history of similar injuries?*
- Yes
- No
Please Explain:*
When was the last time your pet had a similar episode?*
Have you given any medications to help with pain or inflammation?*
- Yes
- No
What medication was given?*
How Much?*
When was the last dose?*
Lumps, bumps, or masses?*
- Yes
- No
When did you first notice the lump?*
Have you noticed any changes in the size of the lump?*
- Yes
- No
Increase or Decrease?*
- Increase
- Decrease
Have you noticed any changes in the consistency of the lump?*
- Yes
- No
How So?
- Harder
- Softer
- No longer mobile
If deemed medically necessary by the attending veterinarian, I authorize the any necessary imaging, blood work or labs including, but not limited to the following.*
- Yes
- No, Call before any diagnostic testing
CPR
In the event your pet should experience cardiac or respiratory arrest while being treated today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are, also, acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.*
- I agree to CPR being performed in case of emergency.
- I elect a “Do not resuscitate” status in case of emergency.
For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival.

Acknowledgements

I am the owner or authorized agent for the pet described above and have the authority to initiate care by executing this consent. By signing this, I certify that I am over eighteen years of age and hereby agree to make myself available by PHONE between the hours of 9:30am – 3:30 pm to aid the doctor with any questions regarding my pet’s history or symptoms.

I agree to pay in full today for services rendered on this date, including those deemed necessary for any medical complications or unforeseen circumstances. Furthermore, I understand regardless of the outcome of treatment, I am responsible for payment of the procedures performed today. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner/authorized agent to notify a staff member of such limitations PRIOR to examination or initiation of treatment for my pet. I am, also, aware that a 50% deposit of detailed treatment plan may be required prior to hospitalization or treatment of my pet.

I am aware of the right to decline any services prior to them being performed and by doing so a second visit may be required with additional costs added, including but not limited to additional exam fees and diagnostic charges.

I understand the practice of veterinary medicine is not an exact science and thus, there are no warranty or guarantees that can be awarded to me as to the results or cure afforded by the treatment or procedures performed here today. I have been awarded the opportunity to discuss any questions I may have regarding the care of my pet to my satisfaction, and it is my responsibility to do so. I accept that my financial obligation remains regardless of any outcome.
*
- I have read and agree.
Signature*
Date*
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Sick Pet Admission Form

Client Information

Patient Information

Dietary Habits

CPR

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