Basic Info

Owner's Name*

First Last

Pet's Name*

Phone number for today*

Reason for visit today*

please be specific

Pet Health History

Please circle if your pet is currently having any of the following:

Diarrhea?*

Yes
No

Vomiting*

Yes
No

Changes in urination or defecation?*

Yes
No

Changes in energy levels?*

Yes
No

If you checked yes to any please explain

What does your pet eat?

include amounts and any treats given

List all medications you give your pet*

including supplements and over the counter medications

When did your pet last eat?*

Fees*

Admittance to hospital ($27.50) + Exam fee ($93.50) +/- Urgent Care fee ($60.50).
Examples of other common fees: Blood work $175.50 and up, Urinalysis $82, Radiographs $531.50 and up, Fluid therapy $73.50 and up

In situations where your pet may be ill it is important to start treatment as soon as possible. Any treatment fees will be in addition to the exam and hospitalization fees for the admit appointment. Please initial one of the following:

I authorize necessary testing and treatment to be started on my pet as soon as possible and understand the veterinarian will call me to discuss recommendations and costs as soon as time allows.

Or

I request an estimate for any expense above the exam and hospitalization fees prior to any testing or treatment for my pet. I understand this may cause a delay in my pet’s care if I cannot be reached immediately.

Authorization

I hereby authorize the veterinarians of Eastside Veterinary Associates to examine, prescribe for, and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand these charges must be paid at the time services are rendered and that a deposit is required for hospitalization or surgical treatment.

Signature of Owner/Agent*

First Last

Date*

Admit Form

Basic Info

Pet Health History

Fees*

Authorization