Day Admission Form | Companion Pet Hospital

We know your pet’s health is important and we thank you for trusting us to care for them. To help us provide the best care possible, please take a few moments to fill out this form completely.

Thank you for your cooperation in letting us assist you.

Select Location

Please select the location you will be visiting(Required)

Companion Pet Hospital – Carmel

Companion Pet Hospital – Fishkill

Client Info

Name(Required)

First Last

What is the best way to reach you today?(Required)

What time does your pet need to be ready for pick-up?(Required)

Patient Info

Name(Required)

DOB/Approx. Age(Required)

Species(Required)

Sex(Required)

Spayed/Neutered?(Required)

What problem are we seeing your pet for today?(Required)

When did the problem start?(Required)

Is it better, same or worse since you first noticed the problem?(Required)

What medications, if any, have you used to treat this problem since it was first noticed?(Required)

What medications does your pet take regularly (include vitamins, supplements or over the counter drugs)?(Required)

When did your pet last eat?(Required)

Any change in diet?(Required)

When did your pet last urinate/defecate?(Required)

If abnormal, please describe:(Required)

Check One of the Following:(Required)

Please call me with an estimate prior to performing diagnostics or treatment.

You can proceed with diagnostics and treatment up to a certain amount.

Do You Have Pet Insurance?(Required)

Yes

Name of Pet Insurance Carrier:(Required)

I authorize the veterinarians of Companion Pet Hospital of Fishkill, and their support staff, to administer treatment and/or perform diagnostic or surgical procedures as deemed necessary.
I assume full responsibility for all charges incurred in the care of my pet and understand that payment is due at the time of service.

Signature(Required)

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Name

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