AMC Chicago-Hospital Admission Form

1
Pet Name
2
Client Name
First Name
Last Name
3
Date of Hospital Admission
Date
Year
Month
Day
4
Please list ALL the surgical procedures or services that you are expecting to be performed today on your pet. If applicable, please specify the location (e.g. left front leg) of any masses to be removed.
1
2
3
5
Has there been any change in your pet’s health since your last appointment?
Yes
No
6
Please describe the changes
7
Appetite
NORMAL
ABNORMAL
UNKNOWN
8
Please describe
9
Vomiting
YES
NO
10
How often and last episode
11
Stools /defecation
NORMAL
ABNORMAL
UNKNOWN
12
Please describe
13
Coughing
YES
NO
14
Please describe
15
Respiration
NORMAL
ABNORMAL
UNKNOWN
16
Please describe
17
Urination
NORMAL
ABNORMAL
UNKNOWN
18
Please describe
19
Energy level
NORMAL
ABNORMAL
UNKNOWN
20
Please describe
21
If pet has had previous surgeries?* This field is required.
YESNO
22
Has your pet ever had general anesthesia?
Yes
No
23
Please list your pet’s previous surgical procedures with the approximate date
24
Did any complications occur during your pet’s anesthesia or recovery period?
Yes
No
25
Please describe
26
Did your pet make a full recovery from the anesthesia within 24 hours?
Yes
No
27
Please describe
28
Has your pet ever shown any adverse reaction to any medication (injection or pill)?
Yes
No
29
Please list
30
What do you feed your pet on a daily basis?
31
Are there any foods that your pet CANNOT eat?
Yes
No
32
Please let us know
33
What time did your pet last eat?
AM
PM
34
Name
Dosage and Frequency
Last Given
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Row 0, Column 1
Row 0, Column 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Name
Row 0, Column 0
Dosage and Frequency
Row 0, Column 1
Last Given
Row 0, Column 2
Name
Row 1, Column 0
Dosage and Frequency
Row 1, Column 1
Last Given
Row 1, Column 2
Name
Row 2, Column 0
Dosage and Frequency
Row 2, Column 1
Last Given
Row 2, Column 2
Name
Row 3, Column 0
Dosage and Frequency
Row 3, Column 1
Last Given
Row 3, Column 2
Name
Row 4, Column 0
Dosage and Frequency
Row 4, Column 1
Last Given
Row 4, Column 2
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35
For dogs, is your pet on a monthly heartworm preventative?
Yes
No
36
What is the name of the product?
Heartgard
Interceptor
Revolution
Other
37
PLEASE BRING ALL MEDICATIONS AND SUPPLEMENTS WITH YOU ON THE DAY OF
SURGERY!
38
If your pet is having a DENTAL PROCEDURE, please select one
I give the doctor permission to remove any teeth, perform a dental bond or excise an oral mass that they deem medically necessary.
I prefer to be contacted by phone first, but in the event I am unable to be reached, please moveforward with performing the medical or surgical procedure the doctor deems medically necessary.
I must be contacted by phone prior to any dental extraction or any additional procedure is performedon my pet.
39
For pets having a surgical procedure or being admitted for any other medical procedure, please select one
I give the doctor permission to do whatever is medically or surgically indicated for my pet today.
I prefer to be contacted by phone first, but in the event I am unreachable, please move forward withperforming the additional medically or surgically indicated procedures.
I must be contacted by phone prior to any additional diagnostics, treatments or procedures THATARE NOT ON my pet’s ESTIMATE before they are performed. If I am unable to be reached, I do not wantthem to be performed.
40
Though the doctors and staff at AMC take anesthesia very seriously and have taken every precautionary measure to ensure the safety of your pet, complications can occur. In the unlikely event of an emergency, do you give the doctor permission to move forward with life saving treatment such as Cardiopulmonary resuscitation (CPR)?
Yes, please attempt to resuscitate my pet.
No, do not attempt to resuscitate my pet.
41
Primary Contact Name and Number
42
Secondary Contact Name and Number
43
May we text you updates on your cell phone
Yes
No
44
Please provide us with the number
45
We want your pet's stay to be as comfortable and stress free as possible. Are there any suggestions youcan provide us with to help us reach this goal?
46
I am aware that payment is expected in full at the time of the discharge appointment.
IF this is not possible, please discuss this with my office manager now. We can assist you in setting up a CARE Credit line of credit.
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Print
48
Signature
Clear
49
Date
Date
Year
Month
Day
50
Email
example@example.com
Should be Empty: