863-453-5700 saundersvetpro@gmail.com

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Admission Form

Fill out our Admission form below! If you have any questions or concerns, please feel free to contact us.

Admission Form

Please Note: Any fields with * are required.

Name *

First

Last

Pet's Name *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Primary Phone *

Secondary Phone

Email *

Who will be dropping off your pet?

Me
Someone else

Name *

First

Last

Primary Phone *

Secondary Phone

Car make, model, and color that you will arrive/arrived in: *

Species *

Dog
Cat

Reason for visit (check all that apply)? *

Annual exam w/vaccines
Wellness exam
Surgical procedure
Injury
Sick/illness
Other

If injury, please explain: *

If sick/illness, please explain: *

If other, please explain: *

Are there any concerns for (check all that apply)? *

Eating
Drinking
Bad breath
Excessive sleeping/lethargy
Weight loss
Weight gain
Itching/scratching/hair loss
Difficulty standing up
Scooting
Shaking head
Car sickness
Vomiting
Diarrhea/abnormal stools
Skin masses/lesions
Urination issues
Sneezing
Coughing
Eye issues
Difficulty breathing
Lameness/painful limp
None of the above

Has your pet's eating increased or decreased? *

Increased
Decreased

Eating concerns – please explain: *

Eating concerns – when did this issue start? *

Has your pet had eating issues in the past? *

Yes
No

If yes, when? *

Has your pet's drinking increased or decreased? *

Increased
Decreased

Drinking concerns – please explain: *

Drinking concerns – when did this issue start? *

Has your pet had drinking issue in the past? *

Yes
No

If yes, when? *

Bad breath concerns – please explain: *

Bad breath concerns – when did this issue start? *

Has your pet had bad breath issue in the past? *

Yes
No

If yes, when? *

Excessive sleeping/lethargy concerns – please explain: *

Excessive sleeping/lethargy concerns – when did this issue start? *

Has your pet had excessive sleeping/lethargy issues in the past? *

Yes
No

If yes, when? *

Weight loss concerns – please explain: *

Weight loss concerns – when did this issue start? *

Has your pet had weight loss issues in the past? *

Yes
No

If yes, when? *

Weight gain concerns – please explain: *

Weight gain concerns – when did this issue start? *

Has your pet had weight gain issues in the past? *

Yes
No

If yes, when? *

Itching/scratching/hair loss concerns – please explain: *

Itching/scratching/hair loss concerns – when did this issue start? *

Has your pet had itching/scratching/hair loss issues in the past? *

Yes
No

If yes, when? *

Difficulty standing up concerns – please explain: *

Difficulty standing up concerns – when did this issue start? *

Has your pet had difficulty standing up in the past? *

Yes
No

If yes, when? *

Scooting concerns – please explain: *

Scooting concerns – when did this issue start? *

Has your pet had scooting issues in the past? *

Yes
No

If yes, when? *

Shaking head concerns – please explain: *

Shaking head concerns – when did this issue start? *

Has your pet had shaking head issues in the past? *

Yes
No

If yes, when? *

Car sickness concerns – please explain: *

Car sickness concerns – when did this issue start? *

Has your pet had car sickness in the past? *

Yes
No

If yes, when? *

Vomiting concerns – please explain: *

Vomiting concerns – when did this issue start? *

Has your pet had vomiting issues in the past? *

Yes
No

If yes, when? *

Diarrhea/abnormal stools concerns – please explain: *

Diarrhea/abnormal stools concerns – when did this issue start? *

Has your pet had diarrhea/abnormal stools in the past? *

Yes
No

If yes, when? *

Skin masses/lesions concerns – please explain: *

Skin masses/lesions concerns – when did this issue start? *

Has your pet had skin masses/lesions in the past? *

Yes
No

If yes, when? *

Urination concerns – please explain: *

Urination concerns – when did this issue start? *

Has your pet had urination issues in the past? *

Yes
No

If yes, when? *

Sneezing concerns – please explain: *

Sneezing concerns – when did this issue start? *

Has your pet had sneezing issues in the past? *

Yes
No

If yes, when? *

Coughing concerns – please explain: *

Coughing concerns – when did this issue start? *

Has your pet had coughing issues in the past? *

Yes
No

If yes, when? *

Eye concerns – please explain: *

Eye concerns – when did this issue start? *

Has your pet had eye issues in the past? *

Yes
No

If yes, when? *

Difficulty breathing concerns – please explain: *

Difficulty breathing concerns – when did this issue start? *

Has your pet had difficulty breathing in the past? *

Yes
No

If yes, when? *

Lameness/painful limp concerns – please explain: *

Lameness/painful limp concerns – when did this issue start? *

Has your pet had lameness/painful limps in the past? *

Yes
No

If yes, when? *

Do you have any specific questions for the doctor today?

What kind of food are you feeding your pet? *

How often do you feed your pet? *

Has your pet had any other food but their own? *

Yes
No

If yes, what? *

When did your pet last eat? *

When did your pet last drink? *

Is your pet currently taking any medication? *

Yes
No

Medication Name: *

Medication Dosage & Frequency: *

Last dose given? *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication Name: *

Medication Dosage & Frequency: *

Last dose given? *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication Name: *

Medication Dosage & Frequency *

Last dose given? *

Do you need a refill on this prescription today? *

Yes
No

Has your pet ever had an adverse reaction to a medication? *

Yes
No

If yes, please explain: *

Is your pet on heartworm prevention? *

Yes
No

If yes, please list medication & last dose: *

Do you need a refill today? *

Yes
No

Is your pet on flea and tick prevention? *

Yes
No

If yes, please list medication & last dose: *

Do you need a refill today? *

Yes
No

Has your pet been exposed to any toxins (environmental or ingested)? *

Yes
No
Unsure

If yes, what? *

If yes, when was your pet exposed? *

Have you noticed any unusual lumps or bumps? *

Yes
No

If yes, where? *

If yes, when did you first notice it/them? *

I, the owner/agent for the pet described above, request and authorize an exam for my pet. I understand that the staff at Saunders Veterinary Services will contact me at the number listed above after my pet has been examined to discuss diagnosis and treatment and will have an initial estimate of charges.

I understand payment is due when my pet is discharged. However, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

Signature *

Date *

Name

Your preferred Avon Park veterinary hospital.

When you bring your pet to our veterinarian clinic in Avon Park, FL, you’re trusting their health and care to the very
best the Avon Park area has to offer.

Questions?

Contact Us



Location

2801 US HWY 27 S
Avon Park, FL 33825

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Contact Information

Phone: 863-453-5700
Fax: 863-453-2549
Email: saundersvetpro@gmail.com

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Hours

Monday – Friday: 8 AM – 5 PM
Saturday: Closed
Sunday: Closed
Closed for lunch: 12:30 PM – 1:30 PM

We proudly serve the pets of Avon Park, FL, and beyond.

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and affordable veterinary care from your pet’s first adventure throughout a long and healthy life.

Name *

First

Last

Email *

Phone

How can we help you? *

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