Feline Patient Admission Form

COVID Questionnaire

Have you or anyone in your household traveled outside of Canada in the last 14 days?*

Yes
No

Are you currently exhibiting any of the following symptoms?*

Yes
No

Fever, cough, shortness of breath, difficulty breathing, sore throat or painful swallowing, runny nose or stuffy nose, feeling unwell/fatigued, conjunctivitis, etc.

Have you or anyone in your household had close contact with someone who is being investigated or confirmed to be a positive case of COVID-19?*

Yes
No

Are you bringing in an animal that has been in contact with a person that has or is COVID-19 positive in the past 14 days?*

Yes
No

As a small business, we still have a mask mandate in effect. Please ensure that you have a mask on prior to walking into the clinic. You are required to provide your own mask for this visit. We appreciate your participation in this.*

I CONSENT

Admission Questions

Consent for Required Carrier*

I consent
I do not have a carrier for my pet, therefore, I will need TVC to provide one for me at time of curbside service.

Tamarack Vet clinic is not responsible for any cat that gets loose from the time of contact at the vehicle to entering the clinic. If you do not have a carrier for your cat, please let our staff member know and we will provide one for you.

Do you or any family members have any food 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*

Describe in detail please

Duration of symptoms for current concerns?*

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?*

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:*

If so, please list name/dose/last given

If your pet was prescribed any pre-visit medications (Gabapentin/Trazodone/Phenobarbital, etc), please list them and what time they were given (if none were given, put N/A):*

Any Known Allergies?*

Any environmental changes?*

Any Reaction to Medications?*

Any Concerns under Anesthesia?*

Any Recent Change in Weight?*

How is their appetite?*

Poor
Good
Excellent

When did they last eat?*

Has There Been Any Sneezing?*

If so, please describe

Has There Been Any Coughing?*

If so, please describe

Has There Been Any Vomiting?*

If so, please describe

Has There Been Any Diarrhea?*

If so, please describe

When was their last bowel movement?*

Have You Noticed Any New Lumps?*

Has There Been Any Recent Change In Drinking Or Urinating Amounts?*

How is their behaviour?*

Lethargic
Normal
Hyperactive

List Previous Health Concerns:*

Do You Have Any Additional Current Concerns?*

Do you have pet insurance, if so, what company?

Please list the policy number.

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

Best phone number to contact you during the time of appointment*

Date

COVID Questionnaire

Admission Questions

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: [email protected]

HOURS

EMERGENCIES

For after-hours please contact either:

Pulse Veterinary Specialists and Emergency
320-450 Ordze Rd Sherwood Park, AB
(780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre (780) 436-5880

Contact Us