Thorpe Animal Hospital

1678 Mayfield Rd
Lapeer, MI 48446

(810)664-2233

www.thorpevet.com

COVID-19 APPOINTMENT FORM

To help protect our clients and employees from exposure to the COVID-19 virus, we are taking appointments for sick/injured pets only at this time. Those existing patients that require vaccines or other services may be scheduled at the doctor's discretion. Our hospital asks that you fill out this form in order to better facilitate the examination of your pet in your absence. Thank you for your patience as we figure out how to provide your pet with necessary care while preventing the spread of COVID-19 in our community. 

PRINTABLE COVID-19 APPOINTMENT FORM

COVID-19 Appointment Form

Client Name First/Last
First Name
Last Name
E-Mail Address :
Are you the owner of this animal?

Yes
No


If no, please type your name

Relationship to owner(s)
Relative
Friend
Neighbor
Other
Has the owner of this animal or you been ill (with cough, fever, or shortness of breath) or diagnosed with COVID-19? (required)

Yes
No


Pet Name

Reason for Drop off

ANY KNOWN ALLERGIES TO VACCINES/MEDICATIONS?

This pet is lethargic

Water intake has

Decreased
Increased
Unchanged


Eating habits have

Decreased
Increased
Unchanged


What food does this pet normally eat (include treats)?
Brand -Wet and dry

Grain Free

Is it a new food?

Please list any human food/treats given.

Is this pet vomiting?

Yes
No


Does this pet have normal stools?

If no

Soft
Diarrhea
Watery
Hard


What color?

This pet has
Lost Weight

Yes
No


Has this pet recently traveled?

If so, where?

Please list all medications, dose and time
Medications

Please list any additional problems

Is this pet currently on Heartworm prevention?

Flea/Tick control

Do you need any medication refills?

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.
Phone
Phone TypePhone Number
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)

Todays Date (required) :

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