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About
Our Hospital Mission
Veterinarians & Staff
Community Involvement
Independently Owned & Operated
Careers
Celebrating Our 20th Anniversary
Resources
Gift Cards
Helpful Pet Care Links
Payment Options
Download Our App
Discounts
Loyalty Rewards Program
Client Education Library
Forms
New Client Form
Boarding Form
Surgery/Admission Form
Patient Intake Form
Release for Medical Records to Malta Animal Hospital
Shop
Pharmacy
Purina Diets
Services
Behavioral Medicine
Daycare & Boarding
Dental Care
Pet Wellness
Surgery & Anesthesia
View All Services
Emergencies
Contact
Make Appointment
518-885-2550
Surgery/Admission Form
"
*
" indicates required fields
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State
ZIP Code
Email
*
Best Contact Number
*
Alternate Phone
Pet Name
*
Weight
*
Species
*
Gender
*
Age
Breed
Microchipped?
*
Yes
No
Emergency Contact
Date and time of Admission
*
MM slash DD slash YYYY
*
Hours
:
Minutes
AM
PM
AM/PM
Current Medications Given
*
Include Dose / Frequency and Last Dose Given
Feeding Instructions
*
Include brand/formula if dry/canned and amount per meal + frequency
All animals will be fed Purina EN (enteric diet) dry and canned unless otherwise requested
Does your pet have any allergies?
*
Yes
No
Have there been any recent surgeries, accidents and/or illnesses?
*
Yes
No
Any limping or difficulties jumping?
*
Yes
No
Is your pet having any trouble breathing?
*
Yes
No
Is your pet suffering from any vomiting?
*
Yes
No
Is your pet suffering from any diarrhea?
*
Yes
No
Is your pet suffering from any coughing?
*
Yes
No
Is your pet suffering from any sneezing?
*
Yes
No
Is your pet having difficulty urinating or defecating? Is eliminating frequently and/or inappropriately?
*
Yes
No
Would you like your pet to have any routine complimentary treatments performed during their visit today?
Ear Cleaning
*
Yes
No
Nail Trim
*
Yes
No
Anal Sac Expression
*
Yes
No
Consent
*
I authorize Malta Animal Hospital to perform diagnostic, therapeutic, and surgical procedures deemed necessary for the health and welfare of my pet. I understand that the attending veterinarian will make all reasonable attempts to contact me at the above phone number prior to the administration of treatment. In the event of life-threatening conditions, I authorize treatment, regardless of whether I can be reached. I assume all financial responsibility for charges incurred related to the care provided and understand that payment for these services will be required in full upon discharge of my pet.
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