Clinic Admission Form

Welcome to Dowlen Road Veterinary Center               Pet’s Name: ______________

Owner's Name  _______________________                 Weight:_________

Address _____________________________

City,State,Zip  _____________________                 Pick Up:_____________

Home #: ________________   Cell #: _____________       Work #: ________________

Circle where you can be reached today or leave an alternate #________________

If you would like to be reached by text message, please specify Cell #________________

 

CLINIC ADMISSION FORM

General clinic policies

1.EXTERNAL PARASITES: Patients entering the clinic should be free of fleas or

ticks. If they are found, <animal> will be treated at your expense.

I understand a flea treatment will be given if the DRVC staff find fleas on

___________. Signing the bottom of this form shows you understand.

Do you want a bath for cleanliness? ________________

Do you want a flea treatment even if we don't find parasites?_____________

Flea Treatment Cost is $18.99    

Do you want _________’s anal glands expressed for additional charge of $10.00 yes  no

 

2.VACCINATIONS: All pets admitted into the hospital should be vaccinated, if

_____________ is not up to date we recommend vaccination. Vaccines are required

for boarding. Vaccination current? ______ Date Due_______ Vaccinate________

 

For SURGICAL CASES read the following:

3.LASER SURGERY OPTION:  Most surgical procedures can be done with our state-of-the-art surgery laser.  It offers less pain and bleeding, and quicker recovery.  Would you like to add this option for an additional $50.00 (one surgery) $75.00(combined surgeries)?  ______________

 

4.PRE-ANESTHETIC SCREENING: Before putting ____________ under anesthesia we want

to minimize any risk, this screening will detect pre-existing conditions that could lead to complications. Knowledge of such conditions allows us to make anesthesia and/or surgery as safe as possible. This cost is $99.00.

______I do wish to have a pre-anesthetic screening done on _____________.

______I do not wish to have a pre-anesthetic screening done on _____________,and

will not hold this clinic responsible for any anesthetic complications

arising from underlying problems that could be detected from these tests.

 

5.PAIN MANAGEMENT: If a surgery is scheduled for _______________.  We offer pain management for post-surgical pain.  You can get a pain shot that lasts for 24 hours and/or pain medicine to take home following surgery:

         

  Pain Shot only:  $18-40 (based on _______________’s weight)     Yes       No    (Circle)

  Take Home Pain Medication only:   $ 10.00 - $30.00   Yes     No    (Circle)

 

6. Fluoride Treatment: For an additional charge of $5.00, while under anesthetic, we can administer a fluoride treatment to _________________’s teeth.        YES        NO     (Circle)

7. Dental Prophy: For $95.00 we can do full teeth cleaning (scale and polish). YES  NO   (Circle)

       If any teeth need to be extracted, there will be a charge of $7.50 per tooth.

We can do dental radiographs for a charge of 1st View: $25.00; additional views $15.00 each; and full mouth $75.00                    YES               NO    (Circle)

 

8. Microchipping: This provides a permanent, positive identification, which cannot be lost,      altered or intentionally removed      $45.00     Yes         No     (Circle)

  

   Personalized Pet Tag?: Fill out separate form.    Yes      No    (Circle)

9.UNFORESEEN TREATMENTS: If unforeseen treatments are noted by the doctor we

strive to take care of them while your pet is here. We will have medications and notes ready at your pick up time, however we do strive to stay within your budget.

If you have a budget concern for today note the maximum here _______________

Payment for all services rendered is expected at the time of service. I authorize treatment and surgery for <animal>. I understand that medicine is not an exact science and that no guarantees of medical results have been implied. As the owner or authorized agent of <animal> I hereby release Dowlen Road Vet. Ct, their agents, servants, or representatives from any and all liability arising from treatment of <animal>. I authorize the doctor to treat emergencies as deemed necessary.

If your pet is boarding, we require all vaccinations to be given here.  We will not be held responsible for any items brought into the clinic for your pet while boarding.

 

Signed_____________________________________ owner or authorized agent.

Employee Initials______________ Date________________