Medical Day Admission Form Medical Day Admission Form Please provide at least 24 hours prior to appointment Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions. Name * Name First Name First Name Last Name Last Name Pet's Name * Email * Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell? * Yes No Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days? * Yes No Note:Masks are now optional to wear on the day of your appointment. Is your pet on medication Yes No What kind? * When was it last given? * Procedure to be admitted for * Phone number where I can be reached today * I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that * I am over eighteen years of age, and hereby consent to the examination of this pet by the veterinarian at this veterinary practice. I am not over eighteen years of age, and hereby consent to the examination of this pet by the veterinarian at this veterinary practice. Any additional treatments or services you would like performed today If you are human, leave this field blank. Next
