Day Admission Form

If my pet is prescribed oral medication to be given at home, I would prefer:


I request and authorize that the veterinarians, agents and employees of Sam Bass Veterinary Wellness & CTCH to perform an examination as well as the above services/procedures on the pet specified on this
In the event that sedation/anesthesia is required to complete exam and above services/procedures:

After examination and completion of said procedures above:

I understand that blood work is not optional and will be performed on ALL anesthetic cases at the doctor’s discretion.
In case of an emergency, I hereby consent to and authorize the performance of such procedures(s) as are necessary and
desirable in the exercise of the veterinarian’s professional judgement to preserve the quality of life for my pet.
I understand that no guarantee of successful treatment has been made as to the results that may be obtained through
the course of treatment undertaken by the veterinarians, agent or employees of Sam Bass Veterinary Wellness & CTCH. I
certify that I understand this release and will assume full financial responsibility of all charges.
All pets staying with SBVW will be checked for fleas and if positive, shall receive a Capstar. Cost of this treatment is $15.
In order to reduce stress and minimize bacterial infection during blood draws and catheter placement, we may need to
shave a small patch of fur from your pet’s leg and/or neck. Please let the receptionist know if there is a reason that this
needs to be avoided.
I am the owner or agent for the owner of the animal(s) described on this form and have the authority to execute this

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Flea Prevention?

Heartworm Prevention?



Has there been a change in appetite?

Has there been a change in drinking?

Has there been a change in activity?

Has there been a change in urination?

Has there been a change in defecation?

Other Symptoms

Coughing, Sneezing, Trouble Breathing, Panting

Nasal/Eye discharge


Itching, Hair loss/dry skin Change in grooming, Fleas/Ticks

Lumps or bumps

Limping/lameness/ difficult jumping

Change in behavior, hiding, increased vocalization