Feline Patient Admission Form

*
- I have NOT recently traveled outside of Canada
- I HAVE recently traveled outside of Canada
*
- I do NOT feel ill or am exhibiting respiratory illness signs
- I AM feeling ill or I AM exhibiting respiratory illness signs
*
- I have NOT been in contact with an individual that has tested positive for COVID-19
- I HAVE been in contact with an individual that HAS tested positive for COVID-19
*
- I am NOT bringing an animal into the clinic that has been around a person that has tested positive for COVID-19. Pets can act as fomites.
- I AM bringing an animal into the clinic that HAS been around a person that HAS tested positive for COVID-19. Pets can act as fomites.
Do you or any family members have any allergies? (ie: peanut butter)*
- Yes
- No
If yes, please list them:*
Owner Name*
First Last
Pet Name*
Age*
Please specify weeks/months/years*
- Weeks
- Months
- Years
Sex*
- Female
- Spayed Female
- Male
- Neutered Male
Reason for appointment*
Date of last vaccinations? What Clinic?*
Any Previous Reaction to Vaccination?*
Are there Any Other Pets in the Household/What Type?*
How Many Cats In The House? How Many Litter Pans?*
Does/Will Your Cat Go Outdoors?*
Select all that apply to your cat:*
- My Cat Goes Outdoors Unsupervised
- My Cat Goes Outdoors Supervised
- My Cat Will Board In A Kennel When We Are Away
- My Cat Is A Hunter
- My Cat Will Travel/Has Traveled Outside Of Alberta
- My Cat Lives With A Cat Who Does Go Outside
- None of the above apply to my cat
If your cat has travelled outside Alberta, please list where and when.*
Date of Last Deworming? Product Used?*
Brand of Food Fed? How Much/How Often? Canned/Dry?*
Treats Fed/Brand?*
List Current Medications and/or Supplements including dose:*
Any Known Allergies?*
Any Reaction to Medications?*
Any Concerns under Anesthesia?*
Any Recent Change in Appetite/Weight?*
Has There Been Any Coughing/Sneezing/Vomiting/Diarrhea?*
Have You Noticed Any New Lumps?*
Has There Been Any Recent Change In Drinking Or Urinating Amounts?*
List Previous Health Concerns:*
Do You Have Any Additional Current Concerns?*
Duration of symptoms for current concerns?*
Do you have pet insurance, if so, what company?
Please list the policy number.
Best phone number to contact you during the time of appointment*
Consent
FOR NEW CLIENTS/PATIENTS ONLY - I hereby grant Tamarack Vet Clinic LTD permission to take photographs of myself and/or my pet(s), and to publish those photographs for any lawful purpose, including but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my name and/or my pet(s) name.

By signing and dating this document, I authorize Tamarack Vet Clinic LTD to edit, alter, share, remix, tweak, build upon or in any way alter the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my or my pet(s) images(s) and name(s) for the personal or commercial purposes outlined above.
Owner Signature
Date
Date Format: MM slash DD slash YYYY

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