Drop Off Consent Form

What are your preferred pronouns?

Do you prefer a written or verbal summary of your pet's visit?*

Written

Verbal

Patient Name*

Species*

Cat

Dog

Breed:*

Age:*

Gender:*

Male

Female

Male - Neutered

Female - Spayed

Does your pet have a microchip?

Yes

No

What is your pet's regular diet? Please include amount given and frequency:*

IS your pet on any heartworm and/or flea protection?*

Yes

No

What brand of heartworm and/or flea protection is your pet on?

When did you last give your pet heartworm and/or flea protection?

Any known allergies to vaccines/medications?*

Yes

No

If your pet has allergies to vaccines/medications, please explain

Does your pet have any anxiety and/or fear of being at the vet?*

Yes

No

If there is anxiety at the vet, have they been prescribed medication and was it successful?

Is your pet on any medications? If so, what are they? Please include strength and frequency.*

Has your pet recently traveled outside of your city?*

Yes

No

If you answered yes, where did you travel to?

Has your pet recently been boarded? *

Yes

No

What is the reason for your pet's visit today?

Medical Problem

Wellness Exam/Vaccines

Imaging Exam: Radiographs/Ultrasound

Other

Diarrhea? Please check all that apply.*

Yes

No

Soft

Liquid

Urgent or Increased frequency

Straining

Mucus

Blood

N/A

Appetite?*

Increased

Decreased

Eating but not regular food

Interested but stops

No interest

N/A

Respiration, check all that apply.*

Coughing

Sneezing

Congestion

Rapid Breathing

Difficulty Breathing

N/A

Skin, check all that apply.*

Itching

Scratching

Chewing

Scabs/Crusts

Redness/Irritation

N/A

Water Consumption:*

Increased

Decreased

Typical

N/A

Urination, check all that apply.*

Increased

Decreased

Straining

Urgent

Blood present

N/A

Limping or painful? During activity? After activity? Observations/Duration:

New lumps, bumps or wounds? If so, where?

I think the following may be bothering him/her. Check all that apply.

Eyes

Ears

Mouth

Neck

Stomach

Back

Legs

Anal Area

Skin

My pet has LOST weight*

Yes

No

My pet has GAINED weight:*

Yes

No

If your pet experienced weight change, was it intential?

Yes

No

I can be reached at this phone number:*

If you cannot be reached at this number, please indicate if you will allow us to pursue initial diagnostic testing or treatment until you can be reached.*

Yes

No

If you selected yes to the above question, do you have an amount your prefer us not to exceed:

Initial diagnostics may include: blood work and/or radiographs and blood pressure If indicated, presumptive and palliative treatment could include fluid support, pain management, warming, symptom control and other supportive medications.

I authorize anesthesia, surgery and medications if needed for abscess, laceration or other wounds, if my pet is presented for one of these problems.*

Yes

No

I understand, and accept that when anesthesia is involved, there are always inherent risks, including death.

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 all charges incurred for this pet.

Please type your name in the box below to serve as your signature acknowledging the above mentioned statement.*

Drop Off Consent Form

What are your preferred pronouns?

Do you prefer a written or verbal summary of your pet's visit?*

Patient Name*

Species*

Breed:*

Age:*

Gender:*

Does your pet have a microchip?

What is your pet's regular diet? Please include amount given and frequency:*

IS your pet on any heartworm and/or flea protection?*

What brand of heartworm and/or flea protection is your pet on?

When did you last give your pet heartworm and/or flea protection?

Any known allergies to vaccines/medications?*

If your pet has allergies to vaccines/medications, please explain

Does your pet have any anxiety and/or fear of being at the vet?*

If there is anxiety at the vet, have they been prescribed medication and was it successful?

Is your pet on any medications? If so, what are they? Please include strength and frequency.*

Has your pet recently traveled outside of your city?*

If you answered yes, where did you travel to?

If you answered yes, where did you travel to?

Has your pet recently been boarded? *

Reason For Visit

What is the reason for your pet's visit today?

Diarrhea? Please check all that apply.*

Appetite?*

Respiration, check all that apply.*

Skin, check all that apply.*

Water Consumption:*

Urination, check all that apply.*

Limping or painful? During activity? After activity? Observations/Duration:

New lumps, bumps or wounds? If so, where?

I think the following may be bothering him/her. Check all that apply.

My pet has LOST weight*

My pet has GAINED weight:*

If your pet experienced weight change, was it intential?

I can be reached at this phone number:*

If you cannot be reached at this number, please indicate if you will allow us to pursue initial diagnostic testing or treatment until you can be reached.*

If you selected yes to the above question, do you have an amount your prefer us not to exceed:

Today's Date:*