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E-Mail Address :
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Are you the owner of this animal?
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If no, please type your name
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Relationship to owner(s)
Relative
Friend
Neighbor
Other
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Pet Name
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Reason for Drop off
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ANY KNOWN ALLERGIES TO VACCINES/MEDICATIONS?
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This pet is lethargic
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Water intake has
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Eating habits have
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What food does this pet normally eat (include treats)? |
Brand -Wet and dry
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Grain Free
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Is it a new food?
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Please list any human food/treats given.
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Is this pet vomiting?
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Does this pet have normal stools?
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If no
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What color?
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This pet has |
Lost Weight
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Has this pet recently traveled?
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If so, where?
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Please list all medications, dose and time |
Medications
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Please list any additional problems
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Is this pet currently on Heartworm prevention?
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Flea/Tick control
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Do you need any medication refills?
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I am the owner/agent for described animal and authorize, and request an exam for this pet.
I understand the doctor will contact me after she has examined my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges. 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 charges incurred for this pet. |
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If I cannot be reached at this number, I authorize initial treatment, including fluid support and other supportive medications be started as indicated for my pet.
I understand, and accept that if anesthesia is elected, there are always inherent risks, including death. |
Signature ( Please Type Name) (required)
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Todays Date (required)
:
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