AMC Chicago-Hospital Admission Form

1

Pet Name

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2

Client Name

First Name

Last Name

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3

Date of Hospital Admission

Date

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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

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5

Has there been any change in your pet’s health since your last appointment?

Yes

No

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6

Please describe the changes

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7

Appetite

NORMAL

ABNORMAL

UNKNOWN

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8

Please describe

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9

Vomiting

YES

NO

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10

How often and last episode

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11

Stools /defecation

NORMAL

ABNORMAL

UNKNOWN

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12

Please describe

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13

Coughing

YES

NO

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14

Please describe

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15

Respiration

NORMAL

ABNORMAL

UNKNOWN

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16

Please describe

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17

Urination

NORMAL

ABNORMAL

UNKNOWN

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18

Please describe

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19

Energy level

NORMAL

ABNORMAL

UNKNOWN

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20

Please describe

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21

If pet has had previous surgeries?* This field is required

YESNO

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22

Has your pet ever had general anesthesia?

Yes

No

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23

Please list your pet’s previous surgical procedures with the approximate date

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24

Did any complications occur during your pet’s anesthesia or recovery period?

Yes

No

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25

Please describe

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26

Did your pet make a full recovery from the anesthesia within 24 hours?

Yes

No

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27

Please describe

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28

Has your pet ever shown any adverse reaction to any medication (injection or pill)?

Yes

No

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29

Please list

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30

What do you feed your pet on a daily basis?

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31

Are there any foods that your pet CANNOT eat?

Yes

No

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32

Please let us know

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33

What time did your pet last eat?

AM

PM

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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

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35

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

Yes

No

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36

What is the name of the product?

Heartgard

Interceptor

Revolution

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37

PLEASE BRING ALL MEDICATIONS AND SUPPLEMENTS WITH YOU ON THE DAY OF
SURGERY!

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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.

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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.

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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.

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41

Primary Contact Name and Number

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42

Secondary Contact Name and Number

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43

May we text you updates on your cell phone

Yes

No

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44

Please provide us with the number

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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?

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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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47

Print

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48

Signature

Clear

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49

Date

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50

Email

example@example.com

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