Patient Day Admittance

Homer Veterinary Clinic PC

326 Woodside Avenue
Homer, AK 99603

(907)235-8960

www.homervet.com

Patient Day Admittance Form

Pet's Name

Species

Breed

Age

Client's Name

Phone
Phone TypePhone Number
Backup Phone
Phone TypePhone Number
Would you prefer to be contacted by text

Primary complaint(s): Please select all that apply to your pet’s current condition.
Behavior Problems
Blood in Stool
Breathing Problems
Coughing
Check Growth
Diarrhea
Decreased Appetite
Ear Problems
Eye Problems
Gagging
Gunshot
Hair Loss
Hit By Car
Lameness/Limping
Increased Thirst
Itchy
Increased Urination
Ingested Foreign Substance
Loss of Balance
Painful
Quills
Sneezing
Shaking Head
Trauma
Vomiting
Weakness
Weight Loss
Wound(s)
Other
When did you first notice these problem(s)? Please outline your observations:

What medications/supplement does your pet currently take?(Please include anything you gave recently, even if it was only once.):

Any other details you would like us to know about for today?

Important: Do you want to be contacted by the veterinarian after an exam has been performed but before we proceed with any treatment?
Yes, call me before doing anything in addition to the exam
No, proceed with whatever treatment is deemed necessary
Authorization
I hereby authorize the attending veterinarian and Homer Veterinary Clinic PC to examine, diagnose, prescribe for, and treat the above described pet. I will assume responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at completion of service or time of release.
Authorize
I agree
Disagree

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