Dental Admit Form Please complete the information below so we can keep our records up to date.Owner’s Name:Pet’s Name:Today’s Date MM slash DD slash YYYY Home Phone:Cell Phone:Work Phone:Which phone number should we use to contact you today? Home Cell Work OtherIf appropriate, would you prefer us to contact you via text message? Yes No[Valid cell number]Email Address: Do you have Pet Insurance? Yes NoIf “Yes”: Which provider is your policy with?Reason(s) for today’s visit:What brand of food do you feed your pet?How much?How often?Has your pet eaten today? Yes NoWhat?What time?Does your pet take any medications and/or nutritional supplements? Yes NoWhat kind and please write when it was given last?Does your pet have any allergies or vaccine reactions? Yes NoIf yes, what are they?Do you use a flea/tick preventative? Yes NoIf yes, what kind?Does your pet have a microchip? Yes NoWould you like one implanted today? Yes No(Cost of a Microchip Implant is $73.19)DogIs your dog given heartworm preventative year-round? Yes NoIf yes, what kind?If yes, date last administered?Will your dog be boarding in a kennel within the next year? Yes NoDoes your dog do any of the following? (Check all that apply): Hunt Run/hike in the woods? Have exposure to livestock urine? Groom them self? Come in contact with other dogs?CatDoes your cat go outside? Yes NoHas your cat ever been tested for leukemia or feline aids? Yes NoIf “No”, would you like your cat to be tested today? Yes NoHas your cat ever been tested for heartworm disease? Yes NoIs your cat on monthly heartworm prevention? Yes NoDog or Cat:Has your pet exhibited any of the following signs, symptoms or behaviors? (Check all that apply) Weight gain Weight loss Appetite increase Appetite decrease Vomiting Diarrhea Constipation/difficult defecation Increased drinking Decreased drinking Soiling/Incontinence/dribbling stool or urine Bad breath Difficulty chewing Drooling Coughing Sneezing Wheezing Gagging Choking Difficulty climbing stairs Uncoordinated Lameness Stiffness Decreased activity Listlessness Weakness Muscle tremors Shaking Seizures Unusual discharge Body odors Scooting rear end Head tilt Ear scratching/rubbing Increase in grooming behavior Decrease in grooming behavior Itching Scratching Poor coat Hair loss Behavior change Skin problems Lumps or bumps? (Please note location on diagrams on back of this page)Diagnostics and Treatment ConsentI hereby authorize Suffield Veterinary Hospital to perform professional services that are, in their opinion, advised for treatment and maintenance of my pet’s health and wellbeing.I also authorize the following, if necessary, to be performed: Blood work X-Rays Sedation/Anesthesia SurgeryPre-Anesthetic Blood Work ConsentIf your pet is here for a procedure involving sedation/anesthesia, please read the following carefully and indicate your preference by signing below. A complete physical exam will be performed prior to any anesthesia/sedation to assure your pet’s health and safety. Along with the physical examination, we strongly recommend a few simple laboratory tests to determine your pet’s ability to tolerate the procedure and assure that it is a low-risk patient. The screening includes a complete blood count and a chemistry profile. This will demonstrate your pet’s ability to metabolize the sedation/anesthesia properly. *ALL PETS 5 YEARS AND OLDER MUST HAVE PRE-ANESTHETIC BLOODWORK DONE BEFORE ANY SEDATION/ANESTHESIA. EVERY DOG MUST HAVE AN ANNUAL HEARTWORM TEST PRIOR TO ANESTHESIA* We have the latest in laboratory equipment/technology which makes this procedure quick, easy, and inexpensive. We are proud to be able to offer this benefit to our clients. There is an additional charge of $150.00 for the screening and we feel it is an important step to ensure your pet’s safety and level of risk.Please initial below to give your consent to the pre-anesthetic blood work and to show that you fully understand that there will be an additional cost for the blood work, and that it is an assurance, not a guarantee of your pet’s suitability for anesthesia. Yes NoAfter Hours Pick-Up PolicyPlease note our business hours and make sure to pick up your pet prior to closing. If you pick up your pet after we close, you will be charged a late pick up fee of $50.00. If you are more than 30 minutes late, your pet will stay overnight at SVH and an appropriate overnight charge will be added to your invoice, in addition to the $50.00 late fee.Payment for Products, Medications and Services RenderedI understand that the invoice resulting from my pet’s admission to Suffield Veterinary Hospital is to be paid in full at the time my pet is discharged from Suffield Veterinary Hospital. I will satisfy payment via the following method: Cash Check Visa/MasterCard//Discover/American Express CareCreditSignatureI am the owner or agent of the aforementioned pet, am at least 18 years of age, and am competent to contract in my own name. I have read this document in its entirety before signing below and I fully understand all of the content in this document and its meaning. I fully understand the impact of signing this release.SignaturePRINTED NAME:Date MM slash DD slash YYYY
