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greentreevets@yahoo.com

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GreenTree Animal Hospital

Day Admit Consent Form

Thank you for choosing us! Please fill out the following form before your scheduled appointment.

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Day Admit Consent Form

Please note: All * fields are required. If you have any questions, please call us at 847-680-6543.

Name *

First

Last

Pet's Name *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Primary Phone *

Secondary Phone

Email *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Who will be dropping off your pet?

Me
Someone else

Name *

First

Last

Primary Phone *

Secondary Phone

Car make, model, and color that you will arrive/arrived in *

Species *

Dog
Cat
Other

If other, please list species *

Reason for visit (check all that apply) *

Annual exam w/vaccines
Wellness exam
Surgical procedure
Injury
Sick/illness
Other

Requested vaccinations/tests/services *

Leptosporosis
Heartworm test
Anal Glands
Lyme
Influenza
Rabies
Fecal
Nail Trim
Distemper
Ear cleaning
Microchip
None of the above

Requested vaccinations/tests/services *

Leukemia
Felv/FIV combo test
Rabies
Fecal
Nail Trim
Distemper
Ear cleaning
Microchip
None of the above

If you are checking in for a surgical appointment please fill out our Surgical Consent Form .

If injury, please explain *

If sick/illness, please explain *

If other, please explain *

Are there any concerns for (check all that apply) *

Eating
Drinking
Bad breath
Excessive sleeping/lethargy
Weight loss
Weight gain
Itching/scratching/hair loss
Difficulty standing up
Scooting
Shaking head
Car sickness
Vomiting
Diarrhea/abnormal stools
Skin masses/lesions
Urination issues
Sneezing
Coughing
Eye issues
Difficulty breathing
Lameness/painful limp
None of the above

Has your pet's eating increased or decreased? *

Increased
Decreased

Eating concerns – please explain *

Eating concerns – when did this issue start? *

Has your pet had eating issue in the past? *

Yes
No

If yes, when? *

Has your pet's drinking increased or decreased? *

Increased
Decreased

Drinking concerns – please explain *

Drinking concerns – when did this issue start? *

Has your pet had drinking issue in the past? *

Yes
No

If yes, when? *

Bad breath concerns – please explain *

Bad breath concerns – when did this issue start? *

Has your pet had bad breath issue in the past? *

Yes
No

If yes, when? *

Excessive sleeping/lethargy concerns – please explain *

Excessive sleeping/lethargy concerns – when did this issue start? *

Has your pet had excessive sleeping/lethargy issue in the past? *

Yes
No

If yes, when? *

Weight loss concerns – please explain *

Weight loss concerns – when did this issue start? *

Has your pet had weight loss issue in the past? *

Yes
No

If yes, when? *

Weight gain concerns – please explain *

Weight gain concerns – when did this issue start? *

Has your pet had weight gain issue in the past? *

Yes
No

If yes, when? *

Itching/scratching/hair loss concerns – please explain *

Itching/scratching/hair loss concerns – when did this issue start? *

Has your pet had itching/scratching/hair loss issue in the past? *

Yes
No

If yes, when? *

Difficulty standing up concerns – please explain *

Difficulty standing up concerns – when did this issue start? *

Has your pet had difficulty standing up in the past? *

Yes
No

If yes, when? *

Scooting concerns – please explain *

Scooting concerns – when did this issue start? *

Has your pet had scooting issues in the past? *

Yes
No

If yes, when? *

Shaking head concerns – please explain *

Shaking head concerns – when did this issue start? *

Has your pet had shaking head issues in the past? *

Yes
No

If yes, when? *

Car sickness concerns – please explain *

Car sickness concerns – when did this issue start? *

Has your pet had car sickness in the past? *

Yes
No

If yes, when? *

Vomiting concerns – please explain *

Vomiting concerns – when did this issue start? *

Has your pet had vomiting issues in the past? *

Yes
No

If yes, when? *

Diarrhea/abnormal stools concerns – please explain *

Diarrhea/abnormal stools concerns – when did this issue start? *

Has your pet had diarrhea/abnormal stools in the past? *

Yes
No

If yes, when? *

Skin masses/lesions concerns – please explain *

Skin masses/lesions concerns – when did this issue start? *

Has your pet had skin masses/lesions in the past? *

Yes
No

If yes, when? *

Urination concerns – please explain *

Urination concerns – when did this issue start? *

Has your pet had urination issues in the past? *

Yes
No

If yes, when? *

Sneezing concerns – please explain *

Sneezing concerns – when did this issue start? *

Has your pet had sneezing issues in the past? *

Yes
No

If yes, when? *

Coughing concerns – please explain *

Coughing concerns – when did this issue start? *

Has your pet had coughing issues in the past? *

Yes
No

If yes, when? *

Eye concerns – please explain *

Eye concerns – when did this issue start? *

Has your pet had eye issues in the past? *

Yes
No

If yes, when? *

Difficulty breathing concerns – please explain *

Difficulty breathing concerns – when did this issue start? *

Has your pet had difficulty breathing in the past? *

Yes
No

If yes, when? *

Lameness/painful limp concerns – please explain *

Lameness/painful limp concerns – when did this issue start? *

Has your pet had lameness/painful limps in the past? *

Yes
No

If yes, when? *

Do you have any specific questions for the doctor today?

What kind of food are you feeding your pet? *

How often do you feed your pet? *

Has your pet had any other food but their own? *

Yes
No

If yes, what? *

When did your pet last eat? *

When did your pet last drink? *

Is your pet currently taking any medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Is your pet taking any other medication? *

Yes
No

Medication name *

Medication dosage & frequency *

Last dose given *

Do you need a refill on this prescription today? *

Yes
No

Has your pet ever had an adverse reaction to a medication? *

Yes
No

If yes, please explain *

Is your pet on heartworm prevention? *

Yes
No

If yes, please list medication & last dose *

Do you need a refill today? *

Yes
No

Is your pet on flea and tick prevention? *

Yes
No

If yes, please list medication & last dose *

Do you need a refill today? *

Yes
No

Has your pet been exposed to any toxins (environmental or ingested)? *

Yes
No
Unsure

If yes, what? *

If yes, when was your pet exposed? *

Have you noticed any unusual lumps or bumps? *

Yes
No

If yes, where? *

If yes, when did you first notice it/them? *

Is it okay to sedate your pet/put your pet under anesthesia if necessary (understand there are always inherent risks, including death)? *

Yes
No

In order for our doctors to do a complete analysis for diagnosis; do we have permission to perform the following if needed?

Please note: Pre-anesthetic bloodwork checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform bloodwork prior to anesthesia or sedation.

Full Chem and CBC *

I give permission to perform
I do not give permission to perform

Full bloodwork on all major organs and full red and white blood cell count; indicated for longer anesthetic procedures and sick patients. *Required for pets over the age of 8 years old* NOTE – We may require this blood work for some procedures and situations

Partial Chem and CBC *

I give permission to perform
I do not give permission to perform

Basic internal organ screen (liver, kidneys) with full red and white blood cell count; for generally healthy, younger patients. *Required for pets over the age of 5 years old*

Ultrasound *

I give permission to perform
I do not give permission to perform

An estimate will be given if an ultrasound is needed.

Radiographs (2 views) *

I give permission to perform
I do not give permission to perform

Urinalysis *

I give permission to perform
I do not give permission to perform

CPR Consent: I, the owner/agent understand that the therapeutic, anesthetic, or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s), staff, and GreenTree Animal Hospital conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. We will administer CPR treatment unless declined. *

Accept
Decline

I, the owner/agent for the pet described above, request and authorize an exam for my pet. I understand that the staff at GreenTree Animal Hospital will contact me at the number listed above after my pet has been examined to discuss diagnosis and treatment and will have an initial estimate of charges.

I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

Signature *

Clear Signature

Date *

Email

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We're Excited To Meet You

Contact us to book an appointment with a veterinarian today!



Phone



Email

greentreevets@yahoo.com



Address

800 E. Park Ave (Rt. 176)
Libertyville, IL, 60048



Hours of Operation

Mon, Tues, Thurs, Fri: 8:00 am - 6:00 pm

Wed: 8:00 am - 2:00 pm ; 3:00 pm - 7:00 pm

Sat: 8:00 am - 12:00 pm

Sun: Closed



Hours of Operation

Mon, Tues, Thurs, Fri:
8:00 am - 6:00 pm

Wed:
8:00 am - 2:00 pm
3:00 pm - 7:00 pm

Sat:
8:00 am - 12:00 pm

Sun:
Closed

Have A Question?

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Email *

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How can we help you? *

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