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Hospitalization Information Sheet
Court Square Animal Hospital
42-34 Crescent Street, Long Island City, NY 11101
Phone: 718-577-4701
Client ID:
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Client Name:
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Patient ID:
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Patient Name:
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Client Address:
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Client Phone #:
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Client Email:
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PET INFORMATION**Ensure Name is As Written on Passport**
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What is the patient being hospitalized for?
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Primary Contact/Phone Number
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Secondary Contact/Phone Number:
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Did you bring the patient any food?
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When was the last time the patient ate?
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Any known allergies?
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Is the patient on any medication?
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Is the patient on any medication?
A
Yes
B
No
If yes, please provide the name of the medication and last time administered:
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Was any calming medication (i.e. oral Gabapentin / Trazodone) administered prior to patient's procedure today?
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Was any calming medication (i.e. oral Gabapentin / Trazodone) administered prior to patient's procedure today?
A
Yes
B
No
If you answered no, are you comfortable with the doctor administering a mild oral calming medication, as deemed necessary by the doctor?
Untitled multiple choice field
A
Yes
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B
No
C
Please note that imaging diagnostics require patients to be still for 15-20 minutes, and many patients benefit from these medications.
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Please note that imaging diagnostics require patients to be still for 15-20 minutes, and many patients benefit from these medications.
A
Yes
B
No
Special Instructions:
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I hereby authorize performance of the services listed above. I understand that I assume financial responsibility of the services rendered and
that payment is due upon discharge of my pet.
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Signature
Submit
