Welcome to American Animal Care Center & American Animal Hospital in Fremont, CA.Veterinary Care for the Bay Area

Owner’s Name:

Pet’s Name:

Date:

Address Correction:

Yes No

Changes Are:

Prior History :

Cats		Dogs
Current	Update Today	Current	Update Today
FVCRP		DHP-Parvo
Feleuk		Bordetella
Rabies		Rabies
FELV Test		Heartworm Test
FIV Test
Bordetella

Yes	No
		Did your Pet eat this Morning?
		Is your pet on Heartworm prevention? Refill?
		Is your pet on Flea Prevention? Refill?
		Has the pet been checked for intestinal parasites in the last 6 months?
		Has your pet had any reaction to Medications?
		Has your pet had any reaction to Vaccines?
		Has your pet had any reaction to Anesthesia?
		Is your pet currently on any medication?
		Name:
		Dosage:

Pro-op Exam:

Temp:

Weight:

Admitting Tech Initals:

Norm	Abn	Norm	Abn	Yes	No
	Ears		Skins			Dleas Present
	Teeth		Nails			Deciduous Teeth Present

Vaccines / Chief Complaint :

History

Has you pet shown any sign of the following?

Vomiting?	How Long?
Diarrhea?	How Long?
Listless?	How Long?
No Appetite?	How Long?
Weakness?	How Long?
Coughing?	How Long?
Gagging?	How Long?
Scratching?	How Long?
Shaking Head?	How Long?
Scooting?	How Long?
Seizures?	How Long?
Urinating? More or less than usual?	How Long?
Drinking? More or less than Usual?	How Long?
Limping? Which leg?
Weight loss or Weight gain?
Unusual lumps or bumps?

Test & Services:

To be done during this Visit:

	Physical Exam		FIV Test
	Intestinal Parasite Exam		Bath Dip
	Deworm if needed		Grooming
	Heartworm Test		Puppy/Kitten Wellness Visit
	FELV Test		Annual Wellness Visit
	Other:
	Anything else we need to know:

May we sedate/anesthesize your pet if necessary? Yes No Call you First

Phone Number we can reach you at today?

Owner Release:
You are to use all reasonable precaution against injury, escape, or death of my pet. The clinic and staff WILL NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that ANY problem that develops with my pet while I’m absent will be treated as deemed best by the staff veterinarians and I ASSUME FULL RESPONSIBILITY for the treatment expense involved. I agree to pay fees for all services rendered at the time my pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorneys fees, and court costs in the event that collection effort become necessary. I agree that the venue of this action will be in the county where the hospital is located. If I neglect to pick up with 5 days of the date below and do not notify you within that time frame, you may assume that the pet is abandoned and are hereby authorize to dispose of the pet as you deem best and / or necessary

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