Admission Form

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Owner Information:

Owner (s)
Street
City,State, Zip
Home Phone
Work Phone
Cell Phone
Other Phone
Email

Patient Information:

Name
Species	Cat Dog Other
Breed
Gender
Spayed/Neutered	Yes No
Age/DOB
Color
Is your pet current for Rabies Vaccination?	Yes No
If Known, Date of Last Rabies Vaccination:
Tag Number
Vaccine given in North Carolina?	Yes No 1 Year 3 Year

VSH will send written information to your referring veterinarian. Examples would include daily updates for hospitalized patients and discharge instructions. Please provide information about the veterinarian who referred you to VSH.

Referring Doctor's Name
Hospital
City, State

If the referring doctor is not your primary care veterinarian, please submit your primary veterinarian's name below so that they will also receive information from VSH.

Primary Doctor's Name
Hospital
City,State

Reason for appointment:

What brought this condition to your attention and when did you first notice?

Please answer the following, providing a brief explanation as needed.

Home Environment:

What is your pet's primary living environment?
Indoors
Outdoors
Both

Is your pet housed with other animals or children?
Yes
No

Has your pet ever lived outside of North Carolina?
Yes
No

Normal Diet:

What does your pet normally eat?
Moist
Dry
Table Foods
Brand

Have there been any changes to your pet's diet recently?
Yes
No

Preventatives:

Is your pet up-to-date on all vaccines?
Yes
No
Unsure

If feline, has your cat been tested for FeLV and FIV?
Yes
No
Unsure
Results/Date

If canine, has your dog been tested for heartworm disease?
Yes
No
Unsure

If canine, is your dog currently receiving a heartworm preventative?
Yes
No
Brand

Medical History:

Please list all medical conditions that your pet is currently being treated for
Yes(please list)

No

Is your pet currently on any medications? (over the counter or prescribed)
Yes (please list names and dosage)

No
Unsure

Has your pet had any adverse reaction to medications or vaccinations?
Yes
No

Has your pet had any past illnesses, injury, or surgery?
Yes (please list)

No
Unsure

Does your pet have heart disease or a heart murmur?
Yes
No
Unsure

Systems Review:

Please select all of the following signs your pet is currently experiencing:
Loss of appetite
Nausea or Vomiting
Flatulence/Diarrhea
Lethargy/Weakness
Weight Loss or Gain
Decreased/Increased thirst
Changes in urinary habits
Unusual behavior(hiding, aggression)
Coughing or gagging
Sneezing, nasal congestion
Eye discharge or discomfort (shaking of the head)
Seizures or collapse
Limping or difficulty walk/stand
Other:

What are your goals for this visit?