Patient Hospitalization
Today’s Date_______________
Your Name _____________________________ Pet’s Name ________________________
We will need to be able to contact you or someone with permission to make medical and financial decisions.
1st phone
______________________
2nd phone
__________________
What is your primary concern today?____________________________________________
When did the issue start? __________
Has your pet had this problem before?
Yes
No If so, when?___________________
Change in Eating +/Weight Gain
Change in Drinking +/- Itching/Scratching
Bad Breath
Difficulty Rising
Excessive Sleeping
Scooting
Weight Loss
Shaking Head
_________________________
Car Sickness
Vomiting
Diarrhea
Skin Masses/Lesions
Urination Issues
Behavioral Problem
Seizure / Date of Last_______
Other____________________
________________________
________________________
I authorize Claus Paws Animal Hospital (CPAH) to perform the following procedures:
Blood Test
Urinalysis
X-rays
Sedation
Vaccines, if due
When did your pet last eat:_____________________________________________________________
Has your pet ever had an adverse reaction to any medication?_________________________________
If so, describe________________________________________________________________________
I understand that a hospitalization appointment is for my convenience, that there is a hospitalization charge of
$11 for each day my pet is hospitalized and that my pet will be examined by the first available veterinarian. I
also understand that emergencies do happen and that an emergency appointment may delay my pet’s appointment
today.
Please call me before treating if my fee will be over $ __________(if left blank, we will call if fee is over $300)
X
Signature
6700 NE 162nd Ave Suite 420 * Vancouver, WA 98682 * 360-896-7449