PATIENT’S ADMISSION RECORD
Date: _____________
Time: ____________AM/PM
BASIC INFORMATION
Home service/In patient/Outpatient: ____________________
New patient/Old patient: ______________________________
NEW PATIENT
Previous Veterinarian/Clinic: _____________________________________________________
Referred by (Vet and Clinic): ______________________________________________________
Did the patient come from another clinic? YES or NO (Please encircle).
If yes, from what veterinary clinic? ________________________________________________
If yes, what is/are the finding of the previous clinic: __________________________________
If Patient was seen by another doctor, medicines given and prescribed: __________________
PET OWNER’S INFORMATION
Name of Pet Owner: ___________________________________________________________________________
Complete Address: ____________________________________________________________________________
Landline Number: ___________________ Cellphone Number: ________________________________________
PATIENT’S INFORMATION
Name of Pet: _________________________ Weight: _______________ Temperature: _____________________
Species (Feline/Canine): ________________ Breed: ________________ Color: ___________________________
Age: ________ Birthday: _______________ Sex (Female/Male): _______________________________________
Diet: _________________________________________________________________________________________
Last Meal Intake (Date and Time): ________________________________________________________________
Water (Tap/Distilled/Mineral): __________________________________________________________________
Last Water Intake (Date and Time): ______________________________________________________________
Chief Complaint/s: _____________________________________________________________________________
Other Complaint/s: ____________________________________________________________________________
Medications given by owner prior to check-up:_____________________________________________________
BRIEF MEDICAL HISTORY
Vaccination Record: ___________________________________________________________________________
Vaccination Card Presented/Not presented: _______________________________________________________
Deworming Record: ___________________________________________________________________________
Anti-rabies Record: ____________________________________________________________________________
History of Surgery/ies: _________________________________________________________________________
History of Allergy/ies: __________________________________________________________________________
ENVIRONMENT
Presence of Mosquitoes: ________________________________________________________________________
Presence/Encounter with Frog: __________________________________________________________________
Presence of Bees and other insects: _______________________________________________________________
Presence of Mouse or Rats: _____________________________________________________________________
Others: ______________________________________________________________________________________
__________________________________
Pet Owner’s Print Name and Signature