AMC Chicago-Hospital Admission Form

1

Pet Name

2

Client Name

First Name

Last Name

3

Date of Hospital Admission

Date

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

Name

Dosage and Frequency

Last Given

Name

Dosage and Frequency

Last Given

Name

Dosage and Frequency

Last Given

Name

Dosage and Frequency

Last Given

Name

Dosage and Frequency

Last Given

35

For dogs, is your pet on a monthly heartworm preventative?

Yes

No

36

What is the name of the product?

Heartgard

Interceptor

Revolution

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.

47

Print

48

Signature

Clear

49

Date

50

Email

example@example.com