Midvalley Animal Clinic
607 S Redwood Road
Salt Lake City Utah 84123 US
8012691213
info@midvalleyanimalclinic.com

EMAIL CALL

Drop Off / Admission Visit Form

You are receiving this form because you have scheduled to bring your pet in for an admitted care visit. We will be examining and treating your pet between scheduled appointments and will treat the most critical patients first. Please understand your pet may be with us for several hours and possibly the entire day. We know it can be scary to leave your pet in our care without you. We hope you find comfort knowing we believe in treating every patient as if they were our own. Our team of trained and experienced animal lovers are devoted to giving our clients and patients the best care possible. So we can best serve you and your pet please fill out the form below with as much detail as possible.

Owner's information form

First name ^*

Last name ^*

Phone ^*

Address ^*

Email ^*

Date of appointment

patient's information

Animal Name ^*

Animal species ^*

Animal breed ^*

Animal gender (e.g. male, female, unknown) ^*

Animal DoB or age ^*

patient history

Please list the symptoms your pet having that brought you here today? ^*

When did your pet's symptoms first start? ^*

Have you noticed any of the following:

Coughing

Diarrhea

Sneezing

Increased Thirst

Increased Urination

Urinating in the home/outside of box

Seizures

Bleeding

Decreased Appetitie

Loss of Consciousness

I have not seen any of these symptoms in my pet

Decreased Thirst

Bruising

Please describe the symptoms you marked above in detail (be sure to include when it started): ^*

My pet stays mostly ^*

Since I first noticed the problem, it has:^*

Worsened

Stayed the same

Improved

What does your pet eat for their diet daily? ^*

Do they get table scraps or treats? ^*

Is your pet current on vaccines?^*

Yes

Unsure

Are there other pets in the household?^*

Yes

Are they showing similar symptoms? ^*

Has your pet traveled outside of Utah?^*

Yes

Is your pet being treated by another veterinary clinic?^*

Yes

Name of veterinary clinic so we may obtain the medical records: ^*

Does your pet take any medications or supplements?^*

Yes

Please list the medications and supplements being given:

Medication/Supplication, Dosage, Frequency, Last Dose Given

Is your pet allergic to any medications or vaccinations?^*

Yes

Please list which medications or vaccines and what the reaction was in the past: ^*

Has your pet been diagnosed with a medical condition (example: heart murmur, epilepsy, cushings, diabetes, etc.)?^*

Yes

Please list all medical conditions:

Condition & Approx Date of Diagnosis

While your pet is here and if they are well enough, would you like to have any other services performed?^*

Yes

Which services would you like done today?

Nail Trim - $35 (Price increases if nail is broken or embedded)

Feline Vaccines - Pricing Below

Anal Gland Expression - $35

Canine Vaccines - Pricing Below

Microchip Implant - $60

Heartworm Prevention - Options Blow

Canine Vaccines

Canine - DHPP-L (Distemper, Hepatitis, Parainfluenza, Parvovirus, Leptospirosis) $40

Canine - Influenza (H3N8, H3N2) $45

Canine - Bordetella $37

Canine - Rabies $27

Feline Vaccines

Feline - FVRCP (Feline Viral Rhinotracheitis, Calicivirus, Panleukopenia) $37

Feline - FeLV (Feline Leukemia Virus) $45

Feline - Rabies $27

Is your pet is current on a heartworm test? This test is required annually and before a preventative is administered.^*

Yes, my pet is current on their heartworm test

No, my pet is due for a heartworm test today - $7 with purchase of preventative (minimum of 6 month supply required)

I am not sure if my pet is current

Heartworm Prevention Select the weight range of your pet for estimated cost. **Please note if you do not know the exact weight of your pet or if they weigh differently than you selected, we will administer the correct dose based on the actual weight. **

Heartworm Prevention - weight range

Diagnostic Permissions

Depending on your pets condition the doctor may recommend bloodwork and/or radiographs. These diagnostic tests may be needed to properly diagnose and treat your pet. In an effort to help get you answers quickly we would like to get your pre-approval for some of these services. Please note: We will not perform any tests we do not feel are required for diagnosing your pets condition. We will call you prior to doing any additional testing. Payment will be due at time of service/pick up. You may be asked to leave a deposit if you are dropping off your pet. We do NOT offer payment plans but we work with Care Credit. To apply please visit www.carecredit.com. Please select the tests below you approve our team to perform if needed: In-house blood work- $235.95 Comprehensive bloodwork including a chemistry panel that may provide indicators of the health and function of your pet’s pancreas, liver, kidney, intestine, thyroid, and many of their other organs and body systems. and a Complete blood count that can detect conditions like anemia and leukemia, and can detect inflammation, blood clotting concerns, and possible infections. Doing this bloodwork same day provides results more quickly than typical lab results, so you can get an answer or diagnosis and decide the next steps right away. In house urinalysis testing - $125.74 Urine testing can be useful to determine if your pet has a urinary tract infection, crystals in their urine which may lead to stones that require surgical removal, and may provide information about other systemic diseases, such as renal or liver function. Doing a urine test on the same day provides results quickly than typical lab results, so you can get an answer or diagnosis and decide the next steps right away. Radiographs (X-rays) - $250 per study Radiographs can be used to detect fractures, abnormalities such as fluid or gas, tumors, bladder stones, injuries, and deformities. Although radiographs may not give enough information to determine the exact cause of your pet's problem, they can help your veterinarian determine which other tests may be needed to make a diagnosis. Injectable and Reversible Sedation - $105.00-$170.00 Sedation may be necessary for certain procedures that would otherwise be too painful to perform while the patient is awake (broken toe nail, foxtail explore, wound care, lancing an abscess, etc.) or for certain situations where the patient's behavior may be aggressive, fearful, or fractious (unable to position properly for x-rays, unable to handle for exam, etc.). It may be required in order to treat your pet. By offering permission beforehand, the vet can perform the procedure and then contact you with an update. Of course, we will not sedate any patients who are not stable or do not require it.

Please select the tests below you approve our team to perform if needed:

In-house blood work- $235.95

Injectable and Reversible Sedation - $105.00-$170.00

In house urinalysis testing - $125.74

Radiographs (X-rays) - $250 per study

I decline all testing until I can speak with a doctor

Owner Consent for CPR or DNR

CPR- Cardio Pulmonary Resuscitation is the treatment provided for a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing (but still has a heartbeat) is more likely to be successful than a pet who has no heartbeat. DNR- Do Not Resuscitate means that if a pet stops breathing or his/her heart has stopped, no effort should be made by our veterinary professionals to attempt to revive the pet, and the pet will be allowed to die.

In the event of a medical crisis:^*

I wish for the doctors of Midvalley Animal Clinic to perform CPR on my pet if he/she suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR, he/she may have permanent health issues. I understand that CPR may cost up to $800.00

I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, my pet will die. I elect to have DNR orders in place.

Do you have any specific questions for the vet? ^*

client signature

Please sign here^*

Clear

Full name ^*

Today's date

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