Day Admittance Release Form | All Cats Hospital

Cat's Name*

Client's Name*

Please provide the phone number we should use to contact you today

Food Brand*

Type*

Canned
Dry
Both

How often is cat fed, and how much?*

Reason for visit*

Has your cat been vomiting?*

Yes
No

Additional services requested (please ask for estimate)

Has your cat ever become ill following vaccines?*

Yes
No

Is your cat on flea or heartworm prevention?*

Yes
No

If so, what type*

Was flea prevention applied within the last 30 days?

Yes
No

When did your cat last eat?*

If your cat is undergoing anesthesia/sedation, it is VITAL that we know if he/she has eaten today to prevent life-threatening complications.

Is you car on any medications?*

Yes
No

Names of Medications

Please indicate which of the following you request*

Do not do ANY diagnostic tests or treatments before speaking with me. I understand that in doing so, valuable time may be lost, causing additional risk to my cat's health and life.
Please proceed with any non-invasive necessary diagnostic tests and treatments up to the following amount (including the exam fee).

Amount*

$150.00
$250.00

If medication is necessary, which do you prefer?*

Pill
Liquid
Either

Acknowledgement

I, the undersigned owner or authorized agent, hereby consent and authorize All Cats Hospital LLC, its veterinarians and agents to receive, prescribe for, board, or operate upon my cat. I understand that no guarantee has been made except reasonable precautions against injury, escape, or illness. I authorize All Cats Hospital LLC. to remove my cat(s) from the premises if weather or building conditions warrant it best for him / her.

If someone other than yourself will be picking up, please indicate

Name of Owner or Agent*

Signature of Owner or Agent*

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