Feline Patient Admission Form

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I have NOT been in contact with an individual that has tested positive for COVID-19

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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.

Owner Name*

First Last

Pet Name*

Age*

Sex*

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:*

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?*