Drop Off Form

The information requested will tell us things that you want us to do for you pet. It is the only way we can be certain that we understand what you want. Therefore, it is important for you to be as specific as possible. If we need addition information, we can contact you at the number you give us. Thank you!

* Indicates required field

Pet Owner Name *

First

Last

Today's date (MM/DD/YY) *

Breed *

Pet's Age *

Phone Number *

Reason for Visit *

When did problem begin *

Has this been treated before? *

Is the patient on any medications not prescribed by our clinic? *

Pet's Appetite *

if Increased or Decreased. for how long would you say? *

Vomiting? *

Liquid or Food? *

How long? *

Diarrhea? *

How long? *

Drinking/Thirst *

How long? *

Lethargic? *

How long? *

Coughing? *

How long? *

Gagging? *

How long? *

Urinating? *

How long? *

Scratching? *

Where and for how long? *

Limping? *

Choose Any *

Front Back Left Right

How long? *

Pain? *

Where? *

How long? *

Shaking head? *

Do you know why/How long? *

Lumps or Bumps you're concerned about? *

Where? *

Weight Loss/Gain? *

When did you first notice? *

Behavioral changes? Please explain. *

Additional info you'd like the Doctor to know: *

Some pets require sedation for exams or painful procedures. May we sedate your pet if necessary? *

Would you like us to call you first before additional procedures or testing? *

After the exam may we proceed with further testing or treatments recommended by the Doctor? *

Owner Release: I understand that all precautions will be taken against injury, escape, or death of my pet. The hospital and staff will NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that ANY problem that develops with my pet while I am absent will be treated as deemed best by staff veterinarians and I assume financial responsibility for the treatments involved.

Before submitting, I acknowledge that I have reviewed the information on this form. *

Yes

Please fill out your name and date, then submit. *

Submit

Drop Off Form

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