Admission Form | Lake City Animal Health & Wellness Center

Client Name(Required)

First Last

Pet’s Name(Required)

Please check the following symptoms that your pet is having

Vomiting

How often?(Required)

Diarrhea

When did it start?(Required)

Consistency?(Required)

Itching

Scale of 1-10 (10 being itching constantly)(Required)

Any particular place?(Required)

Lameness

Where on body?(Required)

Other(Required)

Vaccinations (Due for:)(Required)

Rabies

DHPPCV/FVRCP

Bordetella

Lepto

Lyme

HWT

Fecal

Leukemia

Feline Leukemia/FIV Test

Please describe in detail about the problems your pet is having:(Required)

Certain diagnostic tests (i.e. bloodwork, radiographs) may be required to help diagnose your pet’s problem. A mild sedative may also be necessary. Please authorize the preliminary diagnostics (and sedation if required) and we will call you with an estimate if more extensive procedures or diagnostics are necessary. Please leave a number where you can be reached today. A deposit is required in all cases, with the balance due at the time of dismissal.

Do we have permission to do

Bloodwork

Radiographs

Vaccinations

Signature(Required)

First

Date(Required)

Phone Number(Required)

Phone Number

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