Owner's Name:(Required) First Last Phone(Required)Email(Required) Pet's Name:(Required) First Have you noticed any of the following issues with your pet? (Check all that apply):(Required) Tiring quickly during exercise and/or reluctance to exercise Breathing harder than normal with minimal exercise Dry cough Weight loss Has your pet ever taken heartworm prevention?(Required) Yes No If yes, when was the most recent dose given?Are you currently giving your pet any medication(s)?(Required) Yes No If yes, please list the medsWhere does your pet live most days? [Select One](Required) Indoors (Except for potty breaks) Fully Indoors 50/50 - Indoors/Outdoors Strictly Outdoors What is your pet’s activity level most days? [Select One](Required) Couch Potato Daily Walks Daily Runs High Energy Please limit the personal items you bring while your pet is staying with us to 1 special toy. JAH provides bedding for pets whose pet parents approve of bedding. Please list your pet's 1 special item(Required)I approve for my pet to have bedding while staying at Johnston Animal Hospital and I verify my pet has not had problems in the past eating or chewing on bedding.(Required) Yes No At JAH, we follow the latest heartworm treatment protocol outlined by the American Heartworm Society. The treatment plan has been customized to fit your pet’s specific needs based on their physical exam and medical history. Complications from heartworm treatment may happen, which can cause the treatment plan to vary from what was originally quoted.(Required) I acknowledge the above statement Your pet will need to be under exercise restriction until 6-8 weeks after the last heartworm treatment injection. your pet will need to be restricted to a small room or kennel, preferably indoors. Leash walk ONLY on a short leash when allowed outdoors.(Required) I acknowledge the above statement It is important that you monitor your pet at home throughout heartworm treatment and 6-8 weeks after the final heartworm treatment injection. During the course of heartworm treatment, if you notice labored breathing, noticeable lethargy, pale gums, swollen abdomen and/or constant coughing, please contact us (or an emergency hospital if after-hours). These could be a sign of complications.(Required) I acknowledge the above statement Heartworm disease is passed through mosquitoes. When a mosquito feeds on a heartworm infected animal, they collect microscopic heartworms through the blood meal. After 10-14 days in the mosquito, these microscopic heartworms are then passed to the next dog that is fed on. About 6 months later, they would show positive results on a heartworm test. If your pet lives with other animals, especially dogs, consider having them tested for heartworm disease. Your pet must be free from internal and external parasites and be up to date on all preventative vaccines deemed necessary by their veterinarian. This policy protects your pet as well as other animals during their stay in the hospital. If your pet is not current on vaccinations or shows signs of any parasites, these treatments will be done at your expense. **(Required) I acknowledge the above statement I understand that Johnston Animal Hospital is not open 24-hours; therefore, if my animal is hospitalized or boarding overnight there will not be 24-hour supervision. If I desire 24-hour supervision of my animal, then I understand that I can request to transfer my animal to a 24-hour veterinary emergency or specialty hospital. I acknowledge that the responsibility for transporting my pet to the 24-hour emergency/specialty facility and the additional fees incurred for care at that facility would be my own.(Required) I acknowledge the above statement I understand that if my pet has signs of fleas or ticks, the team at Johnston Animal Hospital will administer a dose of Bravecto to my pet. I understand that I will be charged an additional fee for this treatment.(Required) I acknowledge the above statement I understand that if pet has soiled themselves, the team at Johnston Animal Hospital will give a necessary freshening bath. I understand that I will be charged an additional fee for this treatment.(Required) I acknowledge the above statement Does your pet have any medications that need to be refilled?Addtional Optional Services(Required) Clean Ears Express Anal Glands Pedicure - Cut Nails Pedicure - File Nails No Additional Services Rabies Vaccination Acknowledgement - In accordance with North Carolina law and for the safety of others, I acknowledge that my dog and/or cat must have a current rabies vaccination. If my pet has already been vaccinated, I agree to provide official documentation to Johnston Animal Hospital PRIOR to my pet's appointment, or authorize my previous veterinary provider to do so on my behalf. If I do not provide valid proof of current rabies vaccination before the appointment, I understand that: My pet will receive a rabies vaccine during the visit if the attending veterinarian determines it is medically safe to do so. I am responsible for any charges associated with the rabies vaccine. If the veterinarian determines it is not medically safe at that time, the rabies vaccine will be administered at a future visit when it becomes safe. I also understand that declining the rabies vaccine places me in violation of North Carolina law. In such cases, Johnston Animal Hospital reserves the right to refuse service, and my pet will not be seen.(Required) I understand and agree with the Rabies Vaccination Acknowledgement above I understand that if pet has soiled themselves, the team at Johnston Animal Hospital will give a necessary freshening bath. I understand that I will be charged an additional fee for this treatment.(Required) Yes, I understand Life-Saving Emergency Care(Required)I understand that all procedures will be performed to the best of the abilities of the team at Johnston Animal Hospital. However, I accept that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results. Select ONE option below for your pet so we can be prepared in an event that life-saving emergency care is needed: YES, the hospital doctors and team have my permission to provide emergency treatment and I agree to pay for these services even if the cost exceeds the health care plan. NO, the hospital doctors and team do not have my permission to provide emergency treatment; therefore, I am choosing “Do Not Resuscitate” for my pet. Typed Signature(Required)I certify that I am the owner, or authorized agent for the owner. I hereby consent to and authorize the doctors and team of Johnston Animal Hospital to admit this pet and perform the procedure indicated on this form. I understand I will be given a health care plan to review at the time of my pet's admission to Johnston Animal Hospital. I acknowledge that I am responsible for payment in full for the procedures and treatments at patient discharge.
