Southern Crossing Animal Hospital

Date(Required)

Client / Pet Information

Owner’s Name(Required)

Patient’s Name(Required)

Phone Number(Required)

Email(Required)

What time will you pick up?(Required)

{Pickup must be before 6:00 p.m. A $39.20 late fee will apply if picked up after 6:15 p.m.}

Medical Problem(s)

10 Questions

Describe in detail any issues present

Duration of problem:

What medications/supplements does your pet take?

How is your pet's appetite recently? Decreased / Normal /Increased

What food(s) does your pet eat?

Has your pet eaten anything he/she is not supposed to?

Yes

No

Has your pet been drinking or urinating more?

Yes

No

Has your pet had any vomiting or diarrhea?

Yes

No

Does your pet get groomed, board or go to daycare?

Yes

No

Has your pet been vaccinated in the last year?

Yes

No

Do you authorize a reasonable work-up (lab work, x-rays, etc.)?

Yes

No

Call First

Do you authorize sedation if necessary?

*Additional charge: price varies according to weight

Yes

No

Call First

Admissions Policy

All animals admitted to the hospital must be up to date on all required vaccinations and free of external parasites, i.e. fleas and ticks. I hereby give permission to SCAH staff to update my pet's vaccinations if necessary and to treat any observed external parasitism. I understand that I will be financially responsible for these services. SCAH does not have after-hours staff. If your pet requires overnight care, they will be referred to the Animal Emergency Center.

I understand that all fees are due at the time the services are rendered. In the event of default or non-payment, I, the undersigned, agree to pay all attorney's fees and the cost of collecting such debt.

Owner/Agent Signature(Required)